unit 6

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

2) Bladder

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

2) Furosemide

A patient is admitted with high blood urea nitrogen (BUN) and creatinine levels, and anuria. Based on these findings, the nurse suspects which diagnosis? 1. Urinary tract infection 2. Renal calculi 3. Enuresis 4. Renal failure

4. Renal failure

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

1) Decreased glomerular filtration rate

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

1) Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant.

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

1) Hypokalemia

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

1) Palpating the bladder height. 3) Performing a bladder scan. 4) Asking the patient about his recent voiding history.

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.

1) beef.

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) increases his intake of high-fiber foods. 3) goes to the bathroom to evacuate after meals.

A day after abdominal surgery, a postoperative patient on a surgical unit says to the nurse, "I'm having a problem with a lot of gas. Maybe it's the food I'm eating." What is the appropriate response by the nurse? Select all that apply. 1. "If the problem continues after you go home, you'll need to avoid gas-producing foods, such as beans." 2. "Let's get you out of bed and walking more. This can help with your gas." 3. "When was your last bowel movement? You may be a bit constipated." 4. "I understand. I'll have to call the doctor for insertion of a rectal tube." 5. "We may need to get you ready to go back to surgery to fix this problem."

1. "If the problem continues after you go home, you'll need to avoid gas-producing foods, such as beans." 2. "Let's get you out of bed and walking more. This can help with your gas." 3. "When was your last bowel movement? You may be a bit constipated."

A patient with severe hemorrhoids is incontinent of liquid stool. Which intervention is contraindicated? 1. Apply an indwelling fecal drainage device. 2. Apply an external fecal collection device. 3. Place an incontinence garment on the patient. 4. Place a moisture-resistant pad under the patient's buttocks.

1. Apply an indwelling fecal drainage device.

The nurse is caring for a patient with suspected kidney dysfunction. In reviewing the patient's home medication list, the nurse is most alerted to which medications? Select all that apply. 1. Aspirin 2. Gentamicin 3. Estrogen 4. Ibuprofen 5. Insulin

1. Aspirin 2. Gentamicin 4. Ibuprofen

In advising an older adult who takes laxatives regularly, the nurse would identify which of the following factors? Select all that apply. 1. Consistent use of laxatives is thought to cause, rather that cure, constipation. 2. Habitual use of laxatives may lead to the need for ever-increasing dosages until the intestine fails to work properly. 3. Chronic laxative use can lead to dependency on the medication. 4. Over-the-counter (OTC) laxatives are better than bulking agents. 5. Laxatives use is recommended, if taken regularly.

1. Consistent use of laxatives is thought to cause, rather that cure, constipation. 2. Habitual use of laxatives may lead to the need for ever-increasing dosages until the intestine fails to work properly. 3. Chronic laxative use can lead to dependency on the medication.

The nurse is performing a focused bowel assessment on an older adult. Which physiological changes of aging should alert the nurse to an increased risk for problems associated with bowel elimination? Select all that apply. 1. Decreased sphincter control 2. Decreased peristalsis 3. Increased intestinal muscle tone 4. Decreased physical activity 5. Increased perineal tone

1. Decreased sphincter control 2. Decreased peristalsis

The pediatric nurse educator is teaching a group of parents about distinguishing between food allergies and food intolerance. The nurse should teach parents that which food items are considered to be true food allergens? Select all that apply. 1. Egg whites 2. Shellfish 3. Peanuts 4. Corn 5. Asparagus

1. Egg whites 2. Shellfish 3. Peanuts

The nurse educator is preparing a teaching plan on preventing urinary tract infections (UTIs) for a group of female college students. Which information will the nurse include in the plan? Select all that apply. 1. Empty the bladder soon after sexual intercourse. 2. Urinate when you first feel the urge to void. 3. Wear appropriate underwear, including nylon or synthetic garments. 4. Wipe perineum area from back to front after voiding. 5. Avoid tight-fitting clothes over the groin area.

1. Empty the bladder soon after sexual intercourse. 2. Urinate when you first feel the urge to void. 5. Avoid tight-fitting clothes over the groin area.

A mother tells the nurse at an annual well-child checkup that her 6-year-old son occasionally "wets himself" during the day. Which response by the nurse is appropriate? 1. Explain that occasional wetting is normal in children of this age. 2. Tell the mother to restrict her child's activities to avoid wetting. 3. Suggest "time-out" to reinforce the importance of staying dry. 4. Inform the mother that medication is commonly used to control wetting.

1. Explain that occasional wetting is normal in children of this age

The community health nurse is preparing a teaching plan on food choices that promote normal bowel elimination. Which foods should the nurse teach participants to be sure to include in their diet? Select all that apply. 1. Fresh fruits 2. Lean meats 3. Whole-grain cereals 4. Pastas 5. Peas

1. Fresh fruits 3. Whole-grain cereals 5. Peas

The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves, and: 1. Have the patient void directly into the bedpan. 2. Pour the urine into a graduated container. 3. Read the volume with the container on a flat surface at eye level. 4. Observe the color and clarity of the urine in the bedpan.

1. Have the patient void directly into the bedpan.

Which tasks may be delegated to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Measuring and recording intake and output 2. Performing a bedside dipstick urine test 3. Irrigating a triple lumen catheter 4. Assessing a patient's ability to collect a urine specimen 5. Determining which type of catheter to insert

1. Measuring and recording intake and output 2. Performing a bedside dipstick urine test

The nurse is preparing a young adult, female patient for intravenous pyelogram (IVP). What are the priority actions by the nurse prior to this procedure? Select all that apply. 1. Obtain an informed consent prior to the procedure. 2. Ask whether the patient has an allergy to iodine. 3. Check laboratory results for serum blood urea nitrogen (BUN) and creatinine. 4. Encourage increased fluid intake prior to the procedure. 5. Determine whether the patient has had a barium enema in the past 4 days.

1. Obtain an informed consent prior to the procedure. 2. Ask whether the patient has an allergy to iodine. 3. Check laboratory results for serum blood urea nitrogen (BUN) and creatinine. 5. Determine whether the patient has had a barium enema in the past 4 days.

Which action should the nurse take when beginning bladder training using scheduled voiding? 1. Offer the patient a bedpan every 2 hours while awake. 2. Increase the voiding interval by 30 to 60 minutes each week. 3. Frequently ask the patient if he or she has the urge to void. 4. Lengthen the time between voidings even if urine leakage occurs.

1. Offer the patient a bedpan every 2 hours while awake

The nurse assesses a patient's abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggests which postoperative complication? 1. Paralytic ileus 2. Small bowel obstruction 3. Diarrhea 4. Constipation

1. Paralytic ileus

The nurse is checking for costovertebral angle tenderness. Which technique would the nurse use? 1. Place one palm flat on the 12th rib and spine, on the back. 2. Apply the scanner above the symphysis pubis. 3. Gently percuss the bladder midline abdomen. 4. Calibrate the refractometer before using.

1. Place one palm flat on the 12th rib and spine, on the back.

Which populations are considered high risk for the development of hemorrhoids? Select all that apply. 1. Pregnant women 2. School bus drivers 3. Marathon runners 4. Intensive care unit nurses 5. Desk job workers

1. Pregnant women 2. School bus drivers 5. Desk job workers

Which action should the nurse tell the parent to take to assess a 2-year-old child for pinworms? 1. Press clear cellophane tape against the rectum as soon as the child wakes up. 2. Collect freshly passed stools from the diaper by using a wooden specimen blade. 3. Insert a cotton-tipped swab 2 inches (5 cm) into the rectum to look for visible worms. 4. Do not let the child eat after midnight for an x-ray in the morning.

1. Press clear cellophane tape against the rectum as soon as the child wakes up

A patient with cancer is started on morphine for excruciating pain. Which diagnosis should the nurse add to the patient's care plan 1. Risk for Constipation 2. Constipation 3. Perceived Constipation 4. Chronic Constipation

1. Risk for Constipation

Which factors place the patient at risk for constipation? Select all that apply. 1. Sedentary lifestyle 2. High-dose calcium supplements 3. Lactose intolerance 4. Consumption of spicy food 5. Antibiotic use

1. Sedentary lifestyle 2. High-dose calcium supplements

The nurse identifies the nursing diagnosis Urinary Incontinence in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? 1. Skin breakdown 2. Urinary tract infection 3. Bowel incontinence 4. Renal calculi

1. Skin breakdown

The nurse meets resistance when irrigating a patient's urinary catheter. Which action would the nurse perform first? 1. Slightly turn the patient. 2. Replace the patient's indwelling urinary catheter. 3. Force the fluid through the catheter tubing. 4. Notify the healthcare provider.

1. Slightly turn the patient.

Which age-related changes are considered normal processes in the urinary system that occur in older adults? Select all that apply. 1. The number of functional nephrons decreases with age. 2. The size of the kidney shrinks. 3. Increased bladder muscle tone contributes to incontinence. 4. Loss of bladder elasticity occurs. 5. Prostate enlargement causes urinary incontinence.

1. The number of functional nephrons decreases with age. 2. The size of the kidney shrinks. 4. Loss of bladder elasticity occurs.

The student nurse asks the healthcare provider if an indwelling urinary catheter will be prescribed for a hospitalized patient who is incontinent. The healthcare provider explains that catheters should be utilized only when absolutely necessary because: 1. They are the leading cause of healthcare-associated infections. 2. They are too expensive for routine use. 3. They contain latex, increasing the risk for allergies. 4. They are painful upon insertion for most patients.

1. They are the leading cause of healthcare-associated infections.

The nurse would expect which signs and symptoms for a patient with a suspected urinary tract infection (UTI)? Select all that apply. 1. Urinary frequency 2. Dysuria 3. Polyuria 4. Upper abdominal pain 5. Foul-smelling urine

1. Urinary frequency 2. Dysuria 5. Foul-smelling urine

The nursing instructor is teaching students how to use a fracture pan for patients. What are the most appropriate instructions for this procedure? Select all that apply. 1. Use for patients with a total hip replacement. 2. Elevate the head of the bed before placing the pan under the patient. 3. Place the wide, rounded end of the pan toward the front of the patient. 4. Assist the patient to a side-lying position prior to placing the bedpan. 5. Don sterile gloves to place the patient on the bedpan.

1. Use for patients with a total hip replacement 3. Place the wide, rounded end of the pan toward the front of the patient 4. Assist the patient to a side-lying position prior to placing the bedpan.

A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? 1. Yogurt 2. Pasta 3. Oatmeal 4. Broccoli

1. Yogurt

A client has just voided 50 mL and yet reports that the bladder still feels full. The nurse's next actions should include which of the following? Select all that apply. 1. Palpating the bladder height 2. Obtaining a clean-catch urine specimen 3. Performing a bladder scan 4. Applying a heating pad to the lower abdomen 5. Inserting an incontinence pessary

1. palpating the bladder height. 3. Performing a bladder scan 4. Applying a heating pad to the lower abdomen

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

2) Constipation

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

2) Left side-lying position

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

2) Oranges, raisins, and strawberries

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) Vitamin B 4) Vitamin K

A patient who sustained a spinal cord injury will perform intermittent self- catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure? 1. "I will need to replace the catheter monthly." 2. "I will use clean, rather than sterile, technique at home." 3. "I will remember to inflate the catheter balloon after insertion." 4. "I will dispose of the catheter after use and get a new one each time."

2. "I will use clean, rather than sterile, technique at home."

The nurse instructs a woman about providing a clean-catch urine specimen. Which statement indicates the patient correctly understands the procedure? 1. "I will be sure to urinate into the 'hat' you placed on the toilet seat." 2. "I will wipe my genital area from front to back before I collect the specimen midstream." 3. "I will need to lie still while you put in a urinary catheter to obtain the specimen." 4. "I will collect my urine each time I urinate for the next 24 hours."

2. "I will wipe my genital area from front to back before I collect the specimen midstream."

While performing a physical assessment, the female student nurse tells the instructor that she cannot palpate the patient's bladder. Which statement by the instructor is best? 1. "Try to palpate it again; it takes practice but you will locate it." 2. "Palpate the patient's bladder only when it is distended by urine." 3. "Document this abnormal finding on the patient's chart." 4. "Notify the nurse assigned to the care of your patient."

2. "Palpate the patient's bladder only when it is distended by urine."

The nurse is caring for a patient on the medical-surgical unit. The patient states, "I really don't like to talk about my bowel movements, but what is considered normal for bowel movements?" What is the best response by the nurse? Select all that apply. 1. "We usually like to set an acceptable standard of at least two bowel movement per week." 2. "We can say normal frequency is anything from several times a day to once per week. It depends on your normal pattern." 3. "We also consider whether you have to strain with bowel movements, use laxatives, or have to rush to the toilet." 4. "There is no such thing as normal. All people are different, so no need to worry about it." 5. "Since there are so many different types of normal, this is an issue you should discuss with your primary care provider."

2. "We can say normal frequency is anything from several times a day to once per week. It depends on your normal pattern." 3. "We also consider whether you have to strain with bowel movements, use laxatives, or have to rush to the toilet."

The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patient's rectum? Select all that apply. 1. 2 in. (5.1 cm) 2. 3 in. (7.6 cm) 3. 4 in. (10.2 cm) 4. 5 in. (12.7 cm) 5. 6 in (15.2 cm)

2. 3 in. (7.6 cm) 3. 4 in. (10.2 cm)

Considering normal developmental and physical maturation in children, for which age would a goal of "Achieves bowel control by the end of this month" be most realistic? 1. 18 months 2. 3 years 3. 4 years 4. 5 years

2. 3 years

The nurse is calculating the intake and output (I&O) for a patient. On the I&O record, the following information is noted: milk 140 mL at breakfast, voided 240 mL after breakfast, 120 mL of coffee at 1000, and urinated 300 mL at 1100. Which amount will the nurse document for the total urine output? 1. 240 mL 2. 540 mL 3. 380 mL 4. 300 mL

2. 540 mL

The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis? 1. Prepare the patient for an abdominal flat plate. 2. Collect a stool specimen that contains 20 to 30 mL of liquid stool. 3. Administer a laxative to prepare the patient for a colonoscopy. 4. Test the patient's stool by using a fecal occult test.

2. Collect a stool specimen that contains 20 to 30 mL of liquid stool.

Which tasks may be delegated to an unlicensed assistive personnel (UAP)? Select all that apply. 1. Irrigating a newly created colostomy 2. Collecting and testing a stool sample for occult blood 3. Digitally removing stool as a result of a fecal impaction 4. Assisting with placing a fracture pan on an immobile patient 5. Changing a preexisting, stable ostomy appliance

2. Collecting and testing a stool sample for occult blood 4. Assisting with placing a fracture pan on an immobile patient 5. Changing a preexisting, stable ostomy appliance

Which interventions are appropriate for an older adult patient with urinary incontinence? Select all that apply. 1. Increase the intake of citrus fruits. 2. Consume high-fiber foods regularly. 3. Limit daily caffeine intake to less than 100 mg. 4. Engage in high-impact, aerobic exercise. 5. Keep fluid intake extremely low.

2. Consume high-fiber foods regularly. 3. Limit daily caffeine intake to less than 100 mg.

When changing a diaper, the nurse observes that a 2-day-old infant has passed green-black, tarry stools. What should the nurse do? 1. Notify the provider immediately. 2. Do nothing; this is normal. 3. Give the baby sterile water until the mother's milk comes in. 4. Apply a skin barrier cream to the buttocks to prevent irritation.

2. Do nothing; this is normal.

A client has a history of chronic constipation. Which medications prescribed for the client would alert the nurse to be especially vigilant in observing for constipation and teach the client about preventive measures? Select all that apply. 1. Naproxen 2. Iron 3. Antibiotics 4. Pain medications 5. Ibuprofen

2. Iron 4. Pain medications

Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit (conventional urostomy) for invasive bladder cancer? 1. Patient will resume normal urination pattern by (target date). 2. Patient will perform urostomy self-care by (target date). 3. Patient will perform self-catheterization by (target date). 4. Patient's urine will remain clear with sufficient volume.

2. Patient will perform urostomy self-care by (target date).

A patient is prescribed furosemide, a loop diuretic, for treatment of congestive heart failure. The nurse will monitor for which electrolyte loss? 1. Calcium 2. Potassium 3. Magnesium 4. Phosphorus

2. Potassium

The nurse is caring for a patient who has had an indwelling urinary catheter inserted for the past 5 days. In reviewing and revising the plan of care, what is the most important nursing diagnosis for this patient? 1. Disturbed Body Image 2. Risk for Infection 3. Risk for Impaired Skin Integrity 4. Risk for Decreased Urine Output

2. Risk for Infection

The nurse is performing a colostomy irrigation on a male client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? 1. Notify the physician. 2. Stop the irrigation temporarily. 3. Increase the height of the irrigation. 4. Medicate for pain and resume the irrigation.

2. Stop the irrigation temporarily.

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

3) Diabetes mellitus

The nurse is preparing a client for a computerized tomography with contrast media. Which instruction will the nurse share with the client? 1. "You will have a pressure probe inserted into your rectum." 2. "You will wear your rings and eyeglasses into the procedure room." 3. "You will need to let me know if you are allergic to shellfish." 4. "You will drink 5 to 6 glasses of fluid 90 minutes before the test."

3. "You will need to let me know if you are allergic to shellfish."

The nurse is making assignments for the shift. Which assignment would the nurse delegate to the unlicensed assistive personnel (UAP)? 1. Teaching the patient to perform the Credé's maneuver 2. Irrigating an indwelling catheter 3. Applying a condom catheter 4. Obtaining the patient's urinary history and physical assessment

3. Applying a condom catheter

The nurse is seeing a patient at home with a new colostomy. In formulating the plan of care, what is the priority goal for this patient? The patient will: 1. Adjust emotionally to the colostomy and lifestyle change 2. Verbalize appropriate steps in caring for the colostomy 3. Assume self-care in colostomy management 4. Experience liquid stool with minimal flatus

3. Assume self-care in colostomy management

The nurse is performing an abdominal assessment on a client with irritable bowel syndrome. The nurse has just finished inspection of the abdomen. Which action should the nurse take next? 1. Palpate for distention 2. Percuss for presence of air 3. Auscultate for bowel sounds 4. Feel for masses

3. Auscultate for bowel sounds

The nurse is obtaining a bowel elimination history from an 80-year-old patient. The patient states, "Sometimes when I go to the bathroom, I push real hard, hold my breath, and plug my nose." Which action should the nurse take first? 1. Warn the patient, "You should not hold your breath while straining." 2. Assure the patient, "This does seem to help some people to have a bowel movement." 3. Check the patient's medical history for heart disease or glaucoma. 4. Notify the primary care provider that the patient has reported performing this action.

3. Check the patient's medical history for heart disease or glaucoma.

A patient who has been immobile since sustaining injuries in a motor vehicle accident reports passing hard stools. The nurse encourages the patient to increase daily fluid intake. Which fluids should the patient avoid because of the diuretic effect? Select all that apply. 1. Cranberry juice 2. Water 3. Coffee 4. Lemonade 5. Tea

3. Coffee 5. Tea

A male patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally every 12 hours. The patient reports that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient? 1. Stop taking the drug immediately if diarrhea develops. 2. Take an antidiarrheal agent, such as diphenoxylate. 3. Consume yogurt daily while taking the antibiotic. 4. Increase intake of fiber until the diarrhea stops.

3. Consume yogurt daily while taking the antibiotic.

What position should the female patient assume before the nurse inserts an indwelling urinary catheter? 1. Modified Trendelenburg 2. Prone 3. Dorsal recumbent 4. Semi-Fowler's

3. Dorsal recumbent

A patient has a colostomy in the descending (sigmoid) colon and wants to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, the nurse should teach the patient to: 1. Call the primary care provider if the stoma becomes pale, dusky, or black 2. Limit the intake of gas-forming foods such as cabbage, onions, and fish 3. Irrigate the stoma to produce a bowel movement on a schedule 4. Follow the bananas, white rice, applesauce, and toast (BRAT) diet on a regular basis

3. Irrigate the stoma to produce a bowel movement on a schedule

Which urinary system structure is considered the functional unit responsible for filtration and water absorption? 1. Collecting duct 2. Ureter 3. Nephron 4. Tubular system

3. Nephron

The nurse is caring for a patient who underwent a bowel resection 2 hours ago. The urine output for the past 2 hours totals 50 mL. Which action should the nurse take? 1. Do nothing; this is normal postoperative urine output. 2. Increase the infusion rate of the patient's intravenous (IV) fluids. 3. Notify the provider about the patient's oliguria. 4. Administer the patient's routine diuretic dose early.

3. Notify the provider about the patient's oliguria.

The nurse is inserting an indwelling urinary catheter for a female patient. Upon insertion of the catheter, the nurse accidentally touches the patient's leg and bed sheet with the tip of the catheter. What is the most appropriate action by the nurse? 1. Wipe the tip of the catheter with povidone iodine before proceeding with the insertion. 2. Cleanse the tip of the catheter with alcohol before proceeding with the insertion. 3. Obtain a new catheter and reinsert it using sterile technique. 4. Apply more lubricant and continue to insert the catheter.

3. Obtain a new catheter and reinsert it using sterile technique.

In which area is the appendix located? 1. Inside the sigmoid colon 2. Next to the rectum 3. Off of the cecum 4. Right by the internal sphincter of the anus

3. Off of the cecum

The nurse notes that a patient's indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nurse take? 1. Notify the healthcare provider immediately. 2. Flush the catheter tubing with saline solution. 3. Replace the indwelling urinary catheter. 4. Encourage fluids that increase urine acidity.

3. Replace the indwelling urinary catheter.

What type of indwelling catheter is most suitable for long-term use? 1. Silver-alloy catheter 2. Polyvinyl chloride (PVC) catheter 3. Silicone catheter 4. Triple-lumen catheter

3. Silicone catheter

Which statement best describes how normal voluntary urination occurs? 1. The detrusor muscle relaxes to pass urine through the urethra. 2. The external urethral sphincter contracts to force urine out of the bladder. 3. Stretch receptors send sensory impulse to the voiding reflex center. 4. Voluntary control of the internal urethral sphincter leads to bladder emptying.

3. Stretch receptors send sensory impulse to the voiding reflex center.

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false- negative fecal occult blood test? 1. Vitamin D 2. Iron 3. Vitamin C 4. Thiamine

3. Vitamin C

What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter? 1. Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. 2. Briefly disconnect the catheter from the drainage tube to obtain sample. 3. Withdraw urine through the port using a needleless access device. 4. Obtain the urine specimen directly from the collection bag.

3. Withdraw urine through the port using a needleless access device.

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

4) Hypoactive bowel sounds

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

4) Kegel exercises

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

4) Kock pouch

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.

4) Raise the siderail on the opposite side from where you are working.

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

4) Yogurt and parsley

The nurse is teaching a female patient with stress incontinence how to perform pelvic floor muscle exercises (PFMEs). Which statement indicates the patient understands the procedure? 1. "I will practice by stopping and starting my urine flow." 2. "I will hold each contraction for 20 seconds." 3. "I will perform 30 to 45 contractions each morning." 4. "I will keep the contraction and relaxation times equal."

4. "I will keep the contraction and relaxation times equal."

Which urine specific gravity would be expected in a patient admitted with dehydration? 1. 1.002 2. 1.010 3. 1.021 4. 1.033

4. 1.033

The nurse instilled 60 mL of irrigant into an indwelling fecal drainage device. The client's output was 140 mL. What would the nurse chart as the client's output of stool? 1. 200 mL 2. 140 mL 3. 60 mL 4. 80 mL

4. 80 mL

The enterostomal nurse is conducting a teaching session for patients with new colostomies. Today's topic is self-assessment and signs and symptoms that must be immediately reported to the surgeon. Which sign/symptom should the nurse include in this teaching? 1. Constipation 2. Skin breakdown 3. A stoma that is deep pink to red in color 4. A stoma that is pale, dusky, or black in color

4. A stoma that is pale, dusky, or black in color

A patient's catheter bag is empty 2 hours after it was last drained. The nurse's first action is to: 1. Irrigate the catheter 2. Perform a bladder scan 3. Replace the catheter 4. Check for kinks or compression

4. Check for kinks or compression

The nurse is preparing a patient for an invasive diagnostic test that will provide direct visualization of the rectum, entire large intestine, and distal small bowel. The nurse should teach and give the patient written instructions about which test? 1. Barium enema 2. Ultrasound of the abdomen 3. Sigmoidoscopy 4. Colonoscopy

4. Colonoscopy

The nurse is caring for a patient who has a neobladder. Which action should the nurse take? 1. Insert an indwelling catheter. 2. Replace the collection device, as needed. 3. Inspect the color of the stoma. 4. Encourage performing Kegel exercises.

4. Encourage performing Kegel exercises.

The nurse is caring for a patient who has a continent ileostomy. Which intervention will the nurse add to the plan of care? 1. Change the ostomy appliance as needed. 2. Place a bedside commode by the patient's bed. 3. Keep the collection device below the bladder. 4. Insert a tube into the stoma to drain the pouch.

4. Insert a tube into the stoma to drain the pouch.

The registered nurse is working on a medical-surgical floor. Which behavior by a licensed practical nurse (LPN) would cause the nurse to intervene immediately? 1. Applies a clean ostomy appliance 2. Irrigates a newly created colostomy 3. Applies an external fecal collection system 4. Irrigates an ileostomy

4. Irrigates an ileostomy

Which intervention should the nurse take first to promote micturition in a patient who is having difficulty voiding? 1. Insert an indwelling urinary catheter. 2. Notify the healthcare provider immediately. 3. Obtain an intermittent, straight catheter. 4. Pour warm water over the patient's perineum.

4. Pour warm water over the patient's perineum.

A female patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this finding in the patient's healthcare record? 1. Transient incontinence 2. Overflow incontinence 3. Urge incontinence 4. Stress incontinence

4. Stress incontinence

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

1) Kidneys

The mother of a 3-month-old infant comes to emergency department and states, "My baby has been having severe diarrhea for 4 days. She is crying all the time." In formulating the plan of care for diarrhea, the nurse focuses outcomes on which of the following? Select all that apply. 1. Fluid management 2. Electrolyte balance 3. Skin integrity 4. Excessive crying 5. Ease of stool passage

1. Fluid management 2. Electrolyte balance 3. Skin integrity

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.

3) fruits and vegetables.

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

3) Antibiotic therapy

The nurse is planning care for a renal patient who is prescribed a diuretic medication. In planning care, what is the most appropriate time of day to administer this medication? 1. In the morning 2. In the afternoon 3. In the evening before bedtime 4. After meals

1. In the morning

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

1) 1.001

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

4) "Wait it out. Your son will likely outgrow it."

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

4) Creatinine