nur 101 unit 4 sample
A nurse teaches a client experiencing heartburn to take 1 ½ oz of Maalox when symptoms appear. How many milliliters should the client take? ______ mL. -
45 mL
Which nursing action best reduces risk of excoriation to the mucosal lining of the nose from a nasogastric tube? A. Lubricating the nares with water-soluble lubricant B. Applying a small ice bag to the nose for 5 minutes every 4 hours C. Instilling Xylocaine into the nares once a shift D. Changing the tape holding the tube in place once a shift -
A
A nurse is preparing a teaching session about heart failure for a group of older adults. When planning this session, which action would be important for the nurse to integrate into the session? Select all that apply. A. Allow for extra time to answer questions. B. Keep the lighting in the room dim. C. Plan sessions that are short in duration D. Keep outside distractions to a minimum. E. Tie in new information with things the group is familiar with.
A, C, D, E
The nurse is obtaining a client's medication history. Which of the following medications my cause gastrointestinal bleeding? (Select all that apply.) A. Aspirin B. Cathartics C. Antidiarrheal opiate agents D. Nonsteroidal anti-inflammatory drugs (NSAIDS) -
A, D
The nurse instructs the client to avoid which of the following foods, which could give a false reading on the fecal occult blood test? (Select all the apply.) A. Fish B. Lasagna C. Cranberry juice D. Raw vegetables -
A,D
The nurse should question which order? A. A normal saline enema to be repeated every 4 hours until stool is produced B. A hypertonic solution enema with a patient with fluid volume excess C. A Kayexalate enema for a patient with hypokalemia D. An oil retention enema for a patient using mineral oil laxatives -
C
The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? A. Dysuria B. Flank pain C. Frequency D. Fever and chills -
C
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Of the information below, which is the least important for the evaluation process? A. The incontinence pattern B. State of physical mobility C. Medications being taken D. Age of patient -
D
The nurse knows that most nutrients are absorbed in which portion of the digestive tract? A. Stomach B. Duodenum C. Ileum D. Cecum -
B
Soon after the client's abdominal surgery the nurse includes in the plan of care which of the follwing interventions, which is essential for promoting peristalsis? A. Consumption of a high-fiber diet B. Early ambulation C. Restriction of fluid intake D. Administration of large doses of opioids -
B
When obtaining a nursing history on a client with a suspected gastric ulcer, which signs and symptoms should the nurse expect to assess? (Select all that apply.) A. Epigastric pain at night B. Relief of epigastric pain after eating C. Vomiting D. Weight loss E. Melena -
C, D, E
An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? A. Urinary retention B. Hesitancy C. Urgency D. Urinary incontinence -
D
The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient? A. A 12 year old female with severe abdominal trauma B. A 24 year old male with severe genital warts around the urethra C. A 50 year old male with recent prostatectomy D. A 75 year old female with end-stage renal disease -
A
When irrigating a colostomy, the nurse is sure to use which of the following equipment?: A. An enema set B. A cone-tipped irrigator C. A 50 mL irrigation syringe D. A 16-French Foley catheter with a 30 mL balloon -
B
The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? A. Emptying the drainage bag every 8 hours or when half full B. Kinking the catheter tubing to obtain a urine specimen C. Placing the drainage bag on the side rail of the patient's bed D. Failing to secure the catheter tubing to the patient's thigh -
C
The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? A. Emptying the drainage bag every 8 hours or when half full B. Failing to secure the catheter tubing to the patient's thigh C. Placing the drainage bag on the side rail of the patient's bed D. Kinking the catheter tubing to obtain a urine specimen
C
While undergoing a soapsuds enema, the client complains of abdominal cramping. The nurse should: A. Immediately terminate the infusion B. Advance the enema tubing 2 to 3 inches C. Lower the height of the enema container D. Turn the patient to the supine position
C
A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? A. Turn the patient on the right side to alleviate pressure on the left kidney B. Encourage the patient to increase fluid intake to flush the obstruction C. Administer narcotic medications to alleviate pain D. Monitor the patient for fever, rash, and difficulty breathing -
D
An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? A. Urinary tract infections are unavoidable in the elderly because of a weakened immune system B. Decreasing fluid intake will decrease the amount of urine with bacteria produced C. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection D. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection -
D
A barium enema should be done before an upper gastrointestinal series because of which of the following? A. Retained barium may cloud the colon B. Barium can cause lower gastrointestinal bleeding C. The physicians orders are in that sequence D. Barium is absorbed readily in the lower intestine -
A
A nurse anticipates urodynamic testing for a patient with which symptom? A. Involuntary urine leakage B. Severe flank pain C. Presence of blood in urine D. Dysuria -
A
A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? A. Grape and walnut chicken salad sandwich on whole wheat bread B. Broccoli and cheese soup with potato bread C. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing D. Turkey and mashed potatoes with brown gravy -
A
A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? A. "Drink your nightly glass of milk earlier in the evening." B. "Set your alarm clock to wake you every 2 hours, so you can get up to void." C. "Line your bedding with plastic sheets to protect your mattress." D. "Empty your bladder completely before going to bed." -
A
A nurse is educating a patient on how to irrigate an ostomy bag. Which statement by the patient indicates the need for further instruction? A. "I can use a fleet enema to save money because it contains the same irrigation solution." B. "Sitting on the toilet lets the irrigation sleeve eliminate into the bowl." C. "I should never attempt to reach into my stoma to remove fecal material." D. "Using warm tap water will reduce cramping and discomfort during the procedure." -
A
A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse would expect which other assessment finding? A. Hypoactive bowel sounds B. Jaundice in sclera C. Decreased skin turgor D. Soft tender abdomen -
A
A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? A. "If I get a positive result, I have gastrointestinal bleeding." B. "I should not eat red meat before my examination." C. "I should schedule to perform the examination when I am not menstruating." D. "I will need to perform this test three times if I have a positive result." -
A
A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to: A. Perform pelvic floor exercises B. Drink cranberry juice C. Avoid voiding frequently D. Wear an adult diaper -
A
A patient informs the nurse that she was using laxatives three times daily to lose weight. After stopping use of the laxative, the patient had difficulty with constipation and wonders if she needs to take laxatives again. The nurse educates the patient that: A. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur B. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis C. Natural laxatives such as mineral oil are safer than chemical laxatives for relieving constipation D. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced -
A
A patient is diagnosed with a bowel obstruction. The nurse chooses which type of tube for gastric decompression? A. Salem sump B. Dobhoff C. Sengstaken-Blakemore D. Small bore -
A
A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because A. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void B. The patient does not recognize the physiological signals that indicate a need to void C. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention D. The patient is not drinking enough fluids to produce adequate urine output -
A
After a patient returns from a barium swallow, the nurse's priority is to: A. Encourage the patient to increase fluids to flush out the barium B. Monitor stools closely for bright red blood or mucus, which indicates trauma from the procedure C. Inform the patient that his bowel movements are radioactive, and that he should be sure to flush the toilet three times D. Thicken all patient drinks to prevent aspiration -
A
The doctor has ordered an indwelling catheter inserted in a hospitalized male patient. The nurse is aware of which of the following considerations? 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" into the meatus D. Since it uses a closed system, the risk for urinary infection is absent -
A
The nurse is assessing a patient 2 hours after a colonoscopy. Based on the procedure done, what focused assessment will the nurse include? A. Bowel sounds B. Presence of flatulence C. Bowel movements D. Nausea -
A
The nurse is caring for a client who has just had an upper GI endoscopy. The client's vital signs must be taken every 30 minutes for 2 hours after the procedure. The nurse assigns an unlicensed nursing personnel (UAP) to take the vital signs. One hour later, the UAP reports the client, who was previously afebrile, has developed a temperature of 101.8 ° F (38.8 ° C). What should the nurse do in response to this reported assessment data? A. Promptly assess the client for potential perforation B. Tell the assistant to change thermometers and retake the temperature C. Plan to give the client acetaminophen (Tylenol) to lower the temperature D. Ask the assistant to bathe the client with tepid water -
A
The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because: A. Mastication triggers the digestive system to begin peristalsis. B. More ancillary staff members are available after meal times. C. The digested food needs to make room for recently ingested food. D. The smell of bowel elimination in the room would deter the patient from eating.
A
The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which of the following outcomes would the nurse evaluate as successful for the patient to establish normal defecation? A. The patient reports eliminating a soft, formed stool B. The patient has quit taking opioid pain medication C. The patient's lower left quadrant is tender to the touch D. The nurse hears bowel sounds present in all four quadrants -
A
The nurse is preparing to teach a client about postsurgical care after a laparoscopic cholecystectomy. What determining factors demonstrates that the client is ready and able to learn? A. physical condition B. culture C. social and economic stability D. emotional health
A
The nurse is working with a client who has an ileostomy. Included in the plan of care for this client is instruction that: A. Special skin care is a priority B. A reduction in physical activity will be planned C. Special clothing will need to be ordered to fit around the diversion D. A stoma bag will need to be worn only at night
A
The nurse knows that the ideal time to change an ostomy pouch is: A. Before eating a meal, when the patient is comfortable B. When the patient feels that he needs to have a bowel movement C. When ordered in the patient's chart D. After the patient has ambulated the length of the hallway -
A
The nurse should place the patient in which position when preparing to administer an enema? A. Left Sims' position B. Fowler's C. Supine D. Semi-Fowler's -
A
The nurse would expect the least formed stool to be present in which portion of the digestive tract? A. Ascending B. Descending C. Transverse D. Sigmoid -
A
To reduce patient discomfort during closed catheter irrigation, the nurse should: A. Use room temperature irrigation solution B. Administer the solution as quickly as possible C. Allow the solution to sit in the bladder for at least 1 hour D. Raise the bag of irrigation solution at least 12 inches above the bladder -
A
Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking A. "When was the last time you voided?" B. "Have you noticed any change in your urination patterns?" C. "Do you have a fever or chills?" D. "Do you lose urine when you cough or sneeze?"
A
Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking: A. "When was the last time you voided?" B. "Do you lose urine when you cough or sneeze?" C. "Have you noticed any change in your urination patterns?" D. "Do you have a fever or chills?" -
A
What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? A. Fever and chills B. Difficulty holding in urine C. Increased blood pressure D. Abnormal blood sugar -
A
When a person as a fever or diaphoresis, how would the urine output be described? A. Decreased and highly concentrated B. Decreased and highly dilute C. Increased and concentrated D. Increased and dilute -
A
When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? A. GFR of 20 mL/min B. Urine output of 80 mL/hr C. pH of 6.4 D. Protein level of 2 mg/100 mL -
A
When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? A. Bacteria B. Casts C. Crystals D. Protein -
A
Which class of laxative acts by causing the stool to absorb water and swell? A. Bulk-forming B. Emollient C. Lubricant D. Stimulant -
A
Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective? A. Recording an output that is larger than the amount instilled B. Presence of blood clots or sediment in the drainage bag C. Reduction in discomfort from bladder distention D. Visualizing clear urinary catheter tubing -
A
Which of the following is a nursing priority when caring for a male patient with a condom catheter? A. Preventing the tubing from kinking to maintain free urinary drainage B. Not removing the catheter for any reason C. Fastening the condom tightly to prevent the possible ability of leakage D. Maintaining bed rest at all times to prevent the catheter from slipping off -
A
Which of the following is a true statement about the effects of medication on bowel illumination? A. Diarrhea commonly occurs with amoxicillin clavulanate use B. Anticoagulants cause a white discoloration of the stool C. Narcotic analgesics increased gastrointestinal mobility D. Iron salts in pair digestion and cause a green store -
A
Which of the following is not a function of the large intestine? A. Absorbing nutrients B. Absorbing water C. Secreting bicarbonate D. Eliminating waste -
A
While a cleansing enema is administered to an 80-year-old patient, the patient expresses the urge to defecate. What is the next priority nursing action? A. Positioning the patient in the dorsal recumbent position with a bed pan B. Assisting the patient to the bedside commode C. Stopping the enema cleansing and rolling the patient into right-lying Sims' position D. Inserting a rectal plug to contain the enema solution -
A
The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) A. Asking the patient to void and to discard the first sample B. Keeping the urine collection container on ice C. Withholding all patient medications for the day D. Asking the patient to notify the staff before and after every void -
A, B
A nurse is working with an interpreter to communicate with a client who speaks very little of the nurse's language. Which actions would be appropriate for the nurse to take? Select all that apply. A. Speak to the client rather than the interpreter. B. Rephrase a question using different words if the answer is inappropriate. C. Use simple sentences to convey the verbal message. D. Use metaphors when asking questions to further understanding. E. Talk quickly to ensure that the full message is sent.
A, B, C
A client with a peptic ulcer reports epigastric pain that frequently awakens her during the night. The nurse should instruct the client to do which activities? (Select all that apply.) A. Obtain adequate rest to reduce stimulation B. Eat small, frequent meals throughout the day C. Take all medications on time as ordered D. Sit up for one hour when awakened at night E. Stay away from crowded areas -
A, B, C, D
The nurse begins to suspect a fecal impaction in a client who has not had a stool in 10 days when which of the following occurs: (Select all that apply.) A. The client feels nauseated B. The client oozes liquid stool C. The client has a rounded abdomen D. The client has continuous bowel sounds -
A, B, D
Which of the following are indications for irrigating a urinary catheter? (Select all that apply.) A. Sediment occluding within the tubing B. Blood clots in the bladder following surgery C. Rupture of the catheter balloon D. Bladder infection E. Presence of renal calculi -
A, B, D
Which questions should the nurse include in a cultural assessment? Select all that apply. A. "What do you do to promote good health?" B. "Do have a particular name for this illness?" C. "What do you think about religions other than your own?" D. "What do you think is causing your illness? E. "What religion do you belong to?"
A, B, D, E
To prevent the client from performing Valsalva maneuver, the nurse might request a stool softener for a client with which of the following conditions? (Select all that apply.) A. Glaucoma B. Hypotension C. Cardiovasular disease D. Risk for increased intracranial pressure -
A, C, D
A client with peptic ulcer disease reports that he has been nauseated most of the day and is now feeling light-headed and dizzy. Based upon these findings, which nursing actions would be most appropriate for the nurse to take? (Select all that apply.) A. Administering an antacid hourly until nausea subsides B. Monitoring the client's vital signs C. Notifying the physician of the client's symptoms D. Initiating oxygen therapy E. Reassessing the client in an hour -
B
A client with peptic ulcer disease tells the nurse that he has black stools, which he has not reported to his physician. Based on this information, which nursing diagnosis would be appropriate for this client? A. Ineffective coping related to fear of diagnosis of chronic illness B. Deficient knowledge related to unfamiliarity with significant signs and symptoms C. Constipation related to decreased gastric motility D. Imbalanced nutrition: Less than body requirements related to gastric bleeding -
B
A nurse is asked about the goal of patient education. What is the nurse's best response? The goal of educating others is to help people A. Meet standards of the Nurse Practice Act B. Achieve optimal levels of health C. Become dependent on the health care team D. Provide self-care only in the hospital
B
A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? A. Changing the skin barrier portion of the ostomy pouch daily B. Selecting a pouch that is able to hold excess output to reduce the frequency of pouch emptying C. Thoroughly scrubbing the skin around the stoma to remove excess stool and adhesive D. Measuring the correct size for the barrier device while leaving a 1/8-inch space around the stoma -
B
A nurse is preparing a patient for a magnetic resonance imaging scan. Which nursing action is most important? A. Ensuring that the patient does not eat or drink 2 hours before the examination B. Removing all of the patient's metallic jewelry C. Administering a colon cleansing product 12 hours before the examination D. Obtaining an order for a pain medication before the test is performed -
B
A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? A. "This is probably a false negative; we should rerun the test." B. "Do you take iron supplements?" C. You should schedule a colonoscopy as soon as possible." D. "Sometimes severe stress can alter stool color." -
B
A patient has a nursing diagnosis of impaired urinary elimination related to maturational enuresis. You recognize that your patient is which of the following? A. An older adult that is 65 years of age is incontinent B. A child older than four years of age who has an voluntary urination C. A 12 month old child who is in voluntary urination D. A patient with neurological damage resulting in bladder dysfunction -
B
A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? A. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress B. Utilizing the power of suggestion by turning on the faucet and letting the water run C. Obtaining an order for a Foley catheter D. Administering diuretic medication -
B
A patient with a hip fracture is having difficulty defecating into a bed pan while lying in bed. Which action by the nurse would assist the patient in having a successful bowel movement? A. Administering laxatives to the patient B. Raising the head of the bed C. Preparing to administer a barium enema D. Withholding narcotic pain medication -
B
An older adult's perineal skin appears to be dry and thin with mild excoriation. When providing hygiene after a bowel movement, the nurse should: A. Thoroughly scrub the skin with a wash cloth and hypoallergenic soap B. Apply a skin protective lotion after perineal care C. Tape an occlusive moisture barrier pad to the patient's skin D. Massage the skin with deep kneading pressure -
B
If obstructed, which component of the urination system would cause peristaltic waves? A. Kidney B. Ureters C. Bladder D. Urethra -
B
If the patient was instructed to avoid foods that may have a laxative effect, the nurse would advise the patient to avoid which of the following foods? A. Chinese B. Alcohol C. Eggs D. Pasta -
B
Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they: A. Are embarrassed that they will urinate on the bedding B. Would feel more comfortable assuming a normal voiding position C. Feel they are losing their independence by asking the nursing staff to help D. Are worried about acquiring a urinary tract infection -
B
Mr. T is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test by explaining that it allows which of the following? A. Visual examination of the esophagus and stomach B. Visual examination of the large intestine C. Radiographic examination of the large intestine D. Fluoroscopic examination of the small intestine -
B
Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this? A. They will cause a fecal impaction B. They will cause chronic constipation C. They change the pH of the gastrointestinal track D. They inhibit the intestinal enzymes -
B
The doctor has ordered an indwelling catheter inserted in a hospitalized patient. The nurse is aware of which of the following considerations related to indwelling catheterization? A. the catheter is inserted 2 to 3 inches into the meatus B. the male urethra is more vulnerable to injury during insertion C. in the hospital, medical asepsis is used for catheter insertion D. since it uses a closed system, the risk for urinary infection is absent
B
The nurse finds a client who has been diagnosed with a peptic ulcer surrounded by papers from his briefcase and arguing on the telephone with a coworker. The nurse's response to observing these actions should be based on knowledge that: A. Involvement with his job will keep the client from becoming bored B. A relaxed environment will promote ulcer healing C. Not keeping up with his job will increase the client's stress level D. Setting limits on the client's behavior is an important nursing responsibility -
B
The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? A. Preparing the patient for a second tap water enema B. Donning gloves for digital removal of the stool C. Positioning the patient on the left side D. Inserting a rectal tube -
B
The nurse is caring for a patient who is confined to the bed. The nurse asks the patient if he needs to have a bowel movement 30 minutes after eating a meal because: A. The digested food needs to make room for recently ingested food B. Mastication triggers the digestive system to begin peristalsis C. The smell of bowel elimination in the room would deter the patient from eating D. More ancillary staff members are available after meal times -
B
The nurse is emptying an ileostomy pouch for a patient. Which assessment finding would the nurse report immediately? A. Liquid consistency of stool B. Presence of blood in the stool C. Noxious odor from the stool D. Continuous output from the stoma -
B
The nurse is instructing the client about the use of opioids for pain relief. Included in the teaching is the fact that opioids may cause: A. Headaches B. Constipation C. Hypertension D. Muscle weakness -
B
The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because: A. Catheterization procedures are performed more frequently than indicated B. E. coli pathogens are transmitted during surgical or catheterization procedures C. Perineal care is often neglected by nursing staff D. Bedpans and urinals are not stored properly and transmit infection -
B
The nurse would question an order to insert a urinary catheter on which patient? A. A 26-year-old patient with a recent spinal cord injury at T2 B. A 30-year-old patient requiring drug screening for employment C. A 40-year-old patient undergoing bladder repair surgery D. An 86-year-old patient requiring monitoring of urinary output for renal failure -
B
When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? A. Inserting the catheter using strict clean technique B. Performing hand hygiene before and after providing perineal care C. Fully inflating the catheter's balloon according to the manufacturer's recommendation D. Disconnecting and replacing the catheter drainage bag once per shift -
B
When caring for a patient with urinary retention, the nurse would anticipate an order for: A. Limited fluid intake B. A urinary catheter C. Diuretic medication D. A renal angiogram -
B
When collecting a urine specimen for routine urinalysis from a patient, the nurse must keep in mind which of the following? A. A sterile specimen is required for collection B. Results may be altered if a sample is left standing at room temperature for a long time C. The external meatus requires cleaning with antiseptic soap and water before voiding D. A clean-catch midstream specimen is necessary -
B
When collecting a urine specimen for routine urinalysis from a patient, the nurse must keep in mind which of the following? A. The external meatus requires cleaning with antiseptic soap and water before voiding B. results may be altered of a sample if left standing at room temperature for a long time C. A sterile specimen is required for collection D. a clean catch midstream specimen is necessary
B
Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? A. Self-care deficit related to decreased mobility B. Risk of infection C. Anxiety related to urinary frequency D. Impaired self-esteem related to lack of independence -
B
Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs that prevents ambulation? A. Elevate the head of the bed 45 degrees 60 minutes after breakfast B. Use a mobility device to place the patient on a bedside commode C. Give the patient a pillow to brace against the abdomen while bearing down D. Administer a soap suds enema every 2 hours -
B
Which of the following is the primary function of the kidney? A. Metabolizing and excreting medications B. Maintaining fluid and electrolyte balance C. Storing and excreting urine D. Filtering blood cells and proteins -
B
Which of the following terms notes a patient's inability to void even though the kidneys are producing urine that enters the bladder? A. Urgency B. Retention C. Oliguria D. Dysuria -
B
Which of the following would be an expected outcome for a client with peptic ulcer disease? The client will: A. Demonstrate appropriate use of analgesics to control pain. B. Explain the rationale for eliminating alcohol from the diet C. Verbalize the importance of monitoring hemoglobin and hematocrit every 3 months D. Eliminate contact sports from his or her lifestyle -
B
Which patient is most at risk for increased peristalsis? A. A 5 year old child who ignores the urge to defecate owing to embarrassment B. A 21 year old patient with three final examinations on the same day C. A 40 year old woman with major depressive disorder D. An 80 year old man in an assisted-living environment -
B
Which physiological change can cause a paralytic ileus? A. Chronic cathartic abuse B. Surgery for Crohn's disease and anesthesia C. Suppression of hydrochloric acid from medication D. Fecal impaction -
B
While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find: A. An indwelling Foley catheter B. Reddened irritated skin on the buttocks C. Tiny blood clots in the patient's urine D. Foul-smelling discharge indicative of a UTI -
B
The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient's blood? (Select all that apply.) A. Gravity B. Osmosis C. Diffusion D. Filtration -
B, C
The nurse is teaching a client about enoxaparin sodium for the first time. This client has never given a self-injection before. Which actions are appropriate for the nurse to take? Select all that apply. A. Print out injection rotation diagrams. B. Gather all necessary supplies for injection teaching. C. Review medication data sheets to ensure correct dosage. D. Have the client demonstrate the proper technique for injection. E. Weigh the client to select needle size.
B, C, D
Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.) A. Fever B. Nausea and vomiting C. Headache D. Altered mental status E. Dysuria -
B, C, D
The nurse is caring for a client who has had a gastroscopy. Which of the following signs and symptoms may indicate that the client is developing a complication related to the procedure? (Select all that apply.) A. The client has a sore throat B. The client has a temperature of 100 ° F (37.8 ° C) C. The client appears drowsy following the procedure D. The client has epigastric pain E. The client experiences hematemesis -
B, D, E
Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.) A. Growing urine cultures for up to 12 hours B. Labeling all specimens with date, time, and initials C. Wearing gown, gloves, and mask for all specimen handling D. Allowing the patient adequate time and privacy to void E. Squeezing urine from diapers into a urine specimen cup F. Transporting specimens to the laboratory in a timely fashion G. Placing a plastic bag over the child's urethra to catch urine -
B, D, F, G
The nurse teaches clients with a new colostomy that they can eat whatever roods they like but that which of the follwing foods typically produce gas and should be consumed cautiously? (Select all that apply) A. Pasta B. Beans C. Garlic D. Onions E. Cauliflower -
B,D, E
A client has been taking aluminum hydroxide (Amphojel) 30 mL six times per day at home to treat his peptic ulcer. He tells the nurse that he has been unable to have a bowel movement for 3 days. Based on this information, the nurse would determine that which of the following is the most likely cause of the client's constipation? A. The client has not been including enough fiber in his diet B. The client needs to increase his daily exercise C. The client is experiencing an adverse effect of the aluminum hydroxide D. The client has developed a gastrointestinal obstruction -
C
A client is to take one daily dose of ranitidine (Zantac) at home to treat her peptic ulcer. The client understands proper drug administration of ranitidine when she says that she will take the drug at which of the following times? A. Before meals B. With meals C. At bedtime D. When pain occurs -
C
A client with a Salem sump tube begins to drain stomach contents from the blue "pigtail". Which nursing actions would be appropriate for the nurse to implement at this time? (Select all that apply.) A. Clamp the blue pigtail B. Attach suction to the blue pigtail. C. Irrigate the large lumen with saline D. Position the blu pigtail at the level of the client's ear -
C
A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding would the nurse expect? A. Increased energy levels B. Distended abdomen C. Decreased serum bicarbonate D. Increased blood pressure -
C
A nurse is caring for an older adult patient with fecal incontinence due to cathartic use. The nurse is most concerned about which complication that has the greatest risk for severe injury? A. Rectal skin breakdown B. Contamination of existing wounds C. Falls from attempts to reach the bathroom D. Cross-contamination into the upper GI tract -
C
A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding? A. "Since I'm taking medication, I do not need to worry about proper hygiene." B. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out." C. "My medication may discolor my urine; this should resolve once the medication is stopped." D. "I should not have sexual intercourse until the infection has resolved." -
C
A nurse notifies the provider immediately if a patient with an indwelling catheter: A. Complains of discomfort upon insertion of the catheter B. Places the drainage bag higher than the waist while ambulating C. Has not collected any urine in the drainage bag for 2 hours D. Is incontinent of stool and contaminates the external portion of the catheter -
C
A patient had an ileostomy surgically placed 2 days ago. Which diet would the nurse recommend to the patient to ease the transition of the new ostomy? A. Eggs over easy, whole wheat toast, and orange juice with pulp B. Chicken fried rice with stir fried vegetables and iced tea C. Turkey meatloaf with white rice and apple juice D. Fish sticks with macaroni and cheese and soda -
C
A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? A. Clear the path to the bathroom of all obstacles before bed B. Leave the bathroom light on to illuminate a pathway C. Limit fluid and caffeine intake before bed D. Practice Kegel exercises to strengthen bladder muscles -
C
A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? A. Clear the path to the bathroom of all obstacles before bed. B. Leave the bathroom light on to illuminate a pathway. C. Limit fluid and caffeine intake before bed. D. Practice Kegel exercises to strengthen bladder muscles.
C
A patient is experiencing oliguria. Which action should the nurse perform first? A. Increase the patient's intravenous fluid rate B. Encourage the patient to drink caffeinated beverages C. Assess for bladder distention D. Request an order for diuretics -
C
A patient taking Phenazopyridine (pyridium, a urinary track analgesic) should be cautioned that her urine may change to what color? A. Pale yellow B. Green C. Orange red D. Brown -
C
An ileal conduit is performed on the patient who has a cystectomy. What type of drainage will the patient have from the stoma? A. intermittent urinary drainage B. continuous liquid fecal material C. continuous urine D. formed feces at periodic intervals
C
During the enema the client begins to complain of pain. The nurse notes blood in the return fluid and rectal bleeding. The nurse's next action is to: A. Stop the instillation B. Slow down the rate of instillation C. Stop the instillation and measure vital signs D. Tell the client to breathe -
C
During the nursing assessment the client revels that he has diarrhea and cramping every time he eats ice cream. He attributes this to the cold termperature of the food. However, the nurse begins to suspect the these symptoms might be associated with: A. Food allergy B. Irritable bowel C. Lactose intolerance D. Increased peristalsis -
C
In assessing a 55 year-old client who is in the clinic for a routine physical, the nurse instructs the client about the need to proved a stool specimen for guaiac fecal occult blood testing: A. If the client notices rectal bleeding B. If there is a family history of intestinal polyps C. As part of a routine screening for colon cancer D. If a palpable mass is detected on digital exam -
C
Mr. Bales is 60 years old and alert. He is timid and reluctant to talk about his urinary retention problem. Which part of this plan could create stress for Mr. Bales and possibly increase his inability to urinate? A. Assisting him in assuming his normal voiding position B. Pulling curtains around him to provide privacy during voiding C. Staying with him while voiding D. Offering a urinal or a regular schedule -
C
Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention enema by doing which of the following? A. Administering a large volume solution 500 to 1000 ml B. Mixing milk and molasses and equal parts for an enema C. Instructing the patient to retain the enema for at least 30 seconds D. Administering the enema while the patient is sitting on a toilet -
C
Mrs. Jones is an alert, ambulatory, older nursing home resident, who frequently has difficulty making it to the bathroom in time. The nurse planning her care is aware of which of the following? A. Incontinence is to be expected and a woman of Mrs. Jones age. B. One of every 10 nursing home residents is incontinent C. Keagle exercises performed at regular intervals throughout the day may be helpful D. An indwelling catheter should be inserted as soon as possible -
C
Nursing care for a patient with an indwelling catheter includes which of the following: A. Irrigation of the catheter with a 30 mL of normal saline solution every 4 hours B. Disconnecting and reconnecting the drainage system quickly to obtain a urine sample C. Encourage a generous fluid intake if not contraindicated by the patient D. Telling the patient that burning and irritation are normal, subsiding within a few days -
C
The nurse administers a cathartic to a patient. The nurse determines that the cathartic has had a therapeutic effect when the patient: A. Has a decreased level of anxiety B. Experiences pain relief C. Has a bowel movement D. Passes flatulence -
C
The nurse caring for several clients on a surgical unit notes that one of the clients is Muslim. The nurse decides to remove all pork from the client's meal tray prior to delivering it to the room. What best describes the nurse's action? A. Racism B. Transcultural nursing C. Stereotyping D. Honoring rituals
C
The nurse is documenting a teaching session with a client. Which nursing documentation is the most appropriate and detailed? A. Taught about need for INR monitoring after initiating warfarin therapy. Client's meter used for demonstration and return demonstration. Remediation provided twice to place strip in meter correctly. Questions answered. B. Written material about diabetes mellitus reviewed. Observed demonstration of finger stick and use of glucometer. Will return demonstration with next scheduled glucose monitoring. C. Family requested education on turning client. Explanation of use of draw sheet and body mechanics provided. Family coached through turning and repositioning client. Members state confidence and understanding. D. Education provided. Spouse present during session. Client and spouse state understanding and provided return demonstration of skill.
C
The nurse is preparing to perform a fecal occult blood test. The nurse plans to properly perform the examination by: A. Applying liberal amounts of stool to the guaiac paper B. Testing the quality control section before collecting the specimen section C. Reporting any abnormal findings to the provider D. Applying sterile disposable gloves -
C
The nurse is preparing to teach a client with a peptic ulcer about the diet that should be followed after discharge. The nurse should explain that the diet will most likely consist of which of the following? A. Bland foods B. High-protein foods C. Any foods that are tolerated D. Large amounts of milk -
C
The nurse knows that indwelling catheters are placed before a cesarean because: A. The patient may void uncontrollably during the procedure B. A full bladder can cause the mother's heart rate to drop C. Spinal anesthetics can temporarily disable urethral sphincters D. The patient will not interrupt the procedure by asking to go to the bathroom -
C
The nurse would anticipate inserting a Coudé catheter for which patient? A. An 8-year-old male undergoing anesthesia for a tonsillectomy B. A 24-year-old female who is going into labor C. A 56-year-old male admitted for bladder irrigation D. An 86-year-old female admitted for a urinary tract infection -
C
The nurse would anticipate which diagnostic examination for a patient with black tarry stools? A. Ultrasound B. Barium enema C. Upper endoscopy D. Flexible sigmoidoscopy -
C
The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be: A. Cloudy B. Discolored C. Sweet smelling D. Painful -
C
To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to: A. Cleanse the urethral meatus from the area of most contamination to least B. Initiate the first part of the urine stream directly into the collection cup C. Hold the labia apart while voiding into the specimen cup D. Drink fluids 5 minutes before collecting the urine specimen -
C
Which assessment question should the nurse ask if stress incontinence is suspected? A. "Does your bladder feel distended?" B. "Do you empty your bladder completely when you void?" C. "Do you experience urine leakage when you cough or sneeze?" D. "Do your symptoms increase with consumption of alcohol or caffeine?" -
C
Which statement by a patient with an ileostomy alert the nurse to the need for further education? A. I don't expect to have much of a problem with fecal odor B. I will have to take special precaution to protect my skin around the stoma C. I'm going to have to irrigate my stoma so I have a bowel movement every morning. D. I should avoid gas forming foods like beans to limit funny noises from the stoma
C
Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? A. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." B. "I will complete my bowel prep program the night before the scan." C. "I will be anesthetized so that I lie perfectly still during the procedure." D. "I will ask the technician to play music to ease my anxiety." -
C
Your male client is 60 years old and alert. He is timid and reluctant to talk about his urinary retention problem. Which part of this plan could create stress for this client and possible increase his inability to urinate? A. assisting him in assuming his normal voiding position B. offering a urinal on a regular schedule C. staying with him while voiding D. pulling curtains around him to provide privacy during toileting
C
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply. A. "I can place an aspirin tablet in my pouch to decrease odor." B. "I should empty my ostomy pouch of urine when it is full." C. "I must use a skin barrier to protect my skin from urine." D. "I can usually keep my ostomy pouch on for 3-7 days before changing it." E. "If I limit my fluid intake, I will not have to empty my ostomy pouch as often."
C, D
The nurse has been assigned to provide care for four clients at the beginning of the day shift. In what order should the nurse assess these clients? A. The client awaiting hiatal hernia repair at 11 am B. A client with suspected gastric cancer who is on nothing-by-mouth (NPO) status for tests C. A client with peptic ulcer disease experiencing sudden onset of acute stomach pain D. A client who is requesting pain medication 2 days after surgery to repair a fractured jaw -
C,D, B, A
A cleansing enema is ordered for a 55 year-old client before intestinal surgery. The maximum amount of fluid used is: A. 150 to 200 mL B. 200 to 400 mL C. 400 to 750 mL D. 750 to 1000 mL -
D
A client is admitted to the hospital after vomiting bright red blood and is diagnosed with a bleeding duodenal ulcer. The client develops a sudden, sharp pain in the mid-epigastric region along with a rigid, board-like abdomen. These clinical manifestations most likely indicate which of the following? A. An intestinal obstruction has developed B. Additional ulcers have developed C. The esophagus has become inflamed D. The ulcer has perforated -
D
A client is taking an antacid for treatment of a peptic ulcer. Which of the following statements best indicates that the client understands how to correctly take the antacid? A. "I should take my antacid before I take my other medications." B. "I need to decrease my intake of fluids so that I don't dilute the effects of my antacid." C. "My antacid will be most effective if I take it whenever I experience stomach pains." D. "It is best for me to take my antacid 1 to 3 hours after meals." -
D
A client who recently experience a bout of diarrhea is requesting something to drink. There is an order to force clear liqueids to prevent fluid and electrolyte imbalance. The nurse decides to give the client: A. Ice cream B. A cold fruit pop C. A cup of hot coffee D. Room-temperature bouillon -
D
A client with a peptic ulcer has been instructed to avoid intense physical activity and stress. Which strategy should the client incorporate into the home care plan? A. Conduct physical activity in the morning so that he can rest in the afternoon B. Have the family agree to perform the necessary yard work at home C. Give up jogging and substitute a less demanding hobby D. Incorporate periods of physical and mental rest in his daily schedule -
D
A client with peptic ulcer disease is taking ranitidine (Zantac). What is the expected outcome of this drug? A. Heal the ulcer B. Protect the ulcer surface from acids C. Reduce acid concentration D. Limit gastric acid secretion -
D
A guaiac test has been ordered. The nurse knows that this is a test for: A. Bright red blood B. Dark black blood C. Blood that contains mucus D. Blood that cannot be seen -
D
A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? A. Turkey and mashed potatoes with brown gravy B. Lettuce salad topped with hard-boiled eggs, cheese, and fat-free dressing C. Broccoli and cheese soup with potato bread D. Grape and walnut chicken salad sandwich on whole wheat bread
D
A nurse trained to care for ostomy clients is: A. A gastrointestinal therapist B. A nurse practitioner C. An ostomy practitioner D. A wound-ostomy-continence nurse -
D
A patient asks about treatment for urinary incontinence. The nurse's best response is to advise the patient to: A. Wear an adult diaper. B. Avoid voiding frequently. C. Drink cranberry juice. D. Perform pelvic floor exercises.
D
A patient has constipation and hypernatremia. The nurse prepares to administer which type of enema? A. Oil retention B. Carminative C. Saline D. Tap water -
D
Diarrhea that occurs with a fecal impaction is the result of: A. A clear liquid diet B. Irritation of the intestinal mucosa C. Inability of the client to form a stool D. Seepage of stool around the impaction -
D
Fecal impactions occur in which portion of the colon? A. Ascending B. Descending C. Transverse D. Rectum -
D
Most nutrients and electrolytes are absorbed in: A. The colon B. The stomach C. The esophagus D. The small intestine -
D
Mr. Chang, a hospitalized patient with diabetes mellitus, has developed a UTI. He is 80 years old and has an indwelling catheter in place. Which factor is most likely the cause of the UTI? A. The close proximity of the male genitalia to the rectum B. Decreased immunity C. A high urine glucose level D. The indwelling urinary catheter -
D
The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by: A. Obtaining baseline vital signs after the start of the procedure B. Monitoring the extremity for neurocirculatory function C. Keeping the patient on bed rest for the prescribed time D. Administering an antihistamine medication to the patient -
D
The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. What is the next priority nursing action? A. Preparing the patient for a second tap water enema B. Positioning the patient on the left side C. Inserting a rectal tube D. Donning gloves for digital removal of the stool
D
The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? A. Stoma is protruding from the abdomen B. Stoma is moist C. Stool is discharging from the stoma D. Stoma is purple -
D
The nurse is caring for a patient with Clostridium difficile. Which of the following nursing actions will have the greatest impact in preventing the spread of bacteria? A. Monthly in-services about contact precautions B. Placing all contaminated items in biohazard bags C. Mandatory cultures on all patients D. Proper hand hygiene techniques -
D
The nurse is providing instructions to a Chinese-American client about the frequency and dosages of the take home medicines. When conducting the teaching, the client continuously turns away from the nurse. The nurse should do which of the following appropriate action? A. Hand over a written instruction and discuss only what the client doesn't understand. B. Call the attention of the client by speaking loudly. C. Walk around the client so that the nurse can constantly face the client. D. Continue with the instructions, then confirming client's understanding.
D
The nurse provides knows that a bowel elimination schedule would be most beneficial in the plan of care for which patient? A. A 40 year old patient with an ileostomy B. A 25 year old patient with Crohn's disease C. A 30 year old patient with C. difficile D. A 70 year old patient with stool incontinence -
D
The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? A. Renal ultrasound B. Bladder scan C. KUB x-ray D. Intravenous pyelogram -
D
What is the priority of care after the urinary catheter is removed? A. document size of catheter and client's tolerance of procedure B. documentation of client teaching C. encourage client to eliminate fluid intake D. evaluate client for normal voiding
D
When establishing a diagnosis of altered urinary elimination, the nurse should first: A. Establish normal voiding patterns for the patient B. Encourage the patient to flush kidneys by drinking excessive fluids C. Monitor patients' voiding attempts by assisting them with every attempt D. Discuss causes and solutions to problems related to micturition -
D
Which of the following would the nurse incorporate into the teaching plan for a patient to promote healthy urinary function? A. Drinking more then 2,000 mL per day will cause fluid retention B. The healthy adult should drink four to six 8 oz glasses of water per day C. Children need fewer reminds to drink because of a greater thirst sensitivity D. Caffeine-containing beverages should be monitored to prevent excess intake -
D
