Urinary and Bowel Elimination, Therapeutic Communication

Which lab test can be done at the bedside and requires the least amount of stool specimen? 1. Testing for parasites 2. Fecal occult blood test 3. Clostridium difficile testing 4.Testing for infectious processes

2 Rationales Option 1: Testing for parasites usually requires 2.5 cm of formed stool. Option 2: Fecal occult blood testing requires only a small amount of stool and may be done at the bedside in some facilities. Option 3: Clostridium difficile testing requires 20 to 30 mL of liquid stool. Option 4: Testing for infection in the stool requires approximately 2.5 cm of formed stool or 20 to 30 mL of liquid stool.

What is most important for the nurse to do during the orientation phase of developing a therapeutic relationship with a client? 1.Communicate with active listening. 2.Collect pertinent information in a report to provide the most efficient care. 3.Prepare the nurse and client for future interactions. 4.Ask what name the client would like to be called.

4 Rationales Option 1: This technique would be developed in the working phase. Option 2: This happens during the pre-interaction phase. Option 3: This happens during the termination phase. Option 4: This step establishes rapport and trust with the client.

A client has been having severe diarrhea and fever for the past few days with decreased urinary output. Which would be the expected effect on the urine specific gravity? 1.An increase in specific gravity 2.A decrease in specific gravity 3.No change in specific gravity of urine 4.Unable to determine with the information provided

1 Rationales Option 1: Specific gravity increases with dehydration or fluid loss. Option 2: Specific gravity does not decrease with dehydration or illness. Option 3: Urine specific gravity changes as a result of disease processes in the body. Option 4: The specific gravity can be estimated with a degree of accuracy based on symptoms.

Which medications would the nurse instruct the client with chronic constipation to avoid taking? Select all that apply. 1.Iron 2.Aspirin 3.Opioids 4.Laxatives 5.Antibiotics

1, 3 Rationales Option 1: Iron is used to treat anemia and can cause constipation. Option 2: Aspirin can cause gastric ulcers but does not lead to constipation. Option 3: Opioids are used for pain management and have constipating side effects. Option 4: Laxatives are used to treat constipation, so the client may need to occasionally take these to alleviate symptoms. Option 5: Antibiotics tend to cause diarrhea and do not need to be avoided.

Undigested food first enters the large intestine through which structure? 1. Duodenum 2. Cecum 3. Rectum 4. Sigmoid colon

2 Rationales Option 1: The duodenum is the first part of the small intestine. Option 2: The cecum is the first portion of the large intestine. Option 3: The rectum is the last portion of the large intestine. Option 4: The sigmoid colon is the final, small section of bowel.

Which ion controls acid-base balance? 1. Sodium 2. Oxygen 3.Hydrogen 4. Potassium

3 Rationales Option 1: The presence of sodium controls water reabsorption, as water follows sodium. It does not control acid-base balance. Option 2: A lack of oxygen stimulates the production of erythropoietin. It does not affect acid-base balance. Option 3: The presence of hydrogen controls acid-base balance. Too much hydrogen causes acidosis; too little causes alkalosis. Option 4: Potassium imbalances cause cardiac dysrhythmias. It is not related to acid-base balance.

Which is a normal specific gravity for urine? 1.0.12 2.1.30 3.1.02 4.13.0

3 Rationales Option 1: This specific gravity is well below normal. Option 2: This specific gravity is above normal. Option 3: Normal specific gravity is 1.002 to 1.030. Option 4: This specific gravity is well above normal.

A nurse is auscultating bowel sounds on a client who has had recent abdominal surgery. She hears approximately 1 to 2 sounds per minute in each quadrant. Which condition should the nurse expect? 1. Infection 2. Diarrhea 3. Constipation 4. Ileus

3. Rationales Option 1: One to two bowel sounds per minute is not an indication of infection. Option 2: Diarrhea is usually accompanied by hyperactive bowel sounds. Option 3: One to two bowel sounds per minute is hypoactive bowel sounds, which is an indication of decreased peristalsis in the intestine. Option 4: An ileus is not indicated by a decrease in overall bowel sounds.

The nurse enters the room of a client who is unresponsive. Which intervention best helps the nurse establish communication during the orientation phase? 1.Ask family members how the client would prefer to be addressed. 2.Address the client as "Mr." or "Mrs." as this shows respect towards the client. 3.Call the client by his or her first and last name. 4.Read the medical history to obtain information about how the client is to be addressed.

1 Rationales Option 1: When the nurse is working with an unresponsive client, the best intervention would be to ask family members how the client would prefer to be addressed. Option 2: It may be appropriate for the nurse to address the client by Mr. or Mrs., but this may not be the best way to address the client. Option 3: As a professional, the nurse should not address the client by his or her first name unless granted permission. Option 4: Reading the medical history may not provide this information, as it usually provides medications, past surgeries, and medical diagnoses.

Which client would most benefit from an internal fecal management system? 1.A client incontinent of stool with a sacral decubitus ulcer 2.A younger client diagnosed with a Clostridium difficile infection 3.A client who requires a bowel prep for a colonoscopy procedure 4.A client with irritable bowel syndrome that also has constipation

1 Rationales Option 1: A client who is incontinent of stool and has a sacral decubitus ulcer may end up with stool in the wound. An internal fecal management system would most benefit this client. Option 2: A younger client with a C difficile infection should be able to make it to the commode in time. This client would not require this device. Option 3: A client who requires a bowel prep for a colonoscopy would not need an internal fecal management system, as the client may require enemas for prep. Option 4: A client with irritable bowel syndrome and constipation would not benefit from an internal fecal management device because the client has constipation, not diarrhea.

A new nurse is learning how to communicate assertively. Which is an example of ineffective communication by the nurse? 1. "Why haven't you ordered Mr. Smith's pain medication yet?" 2. "I have an idea about how to transfer Mr. Jones to the gurney and would like your input too." 3."I am not an expert on pain management so I was hoping you could help me understand the pain protocol." 4."I'm not sure I understand this order. Could you please clarify it for me?"

1 Rationales Option 1: Assertive communication involves using "I" statements. Starting a sentence with "why" can be inflammatory. Option 2: This statement focuses on the process and allows for collaboration. Option 3: This statement allows for collaboration and learning from other health-care providers with respect. Option 4: For client safety, it is better to ask for clarification of an order that is unclear or confusing. Use the CUS words: Concerned, Uncomfortable, and Safety.

Which communication technique allows the nurse to provide input while discussing goals at the client's bedside? 1. Client rounding 2. Audio recording 3. Care conference forms 4. Standardized report forms

1 Rationales Option 1: Client rounding is a collaborative approach that allows nurses and health-care providers to equally discuss the plan of treatment and client goals at the bedside. Option 2: The nurse uses a recording device to verbalize end-of-shift reports about the client in the break room, not at the client's bedside. Option 3: A client care conference is usually held in a conference room and has representation from all involved in the client's care. This is not done at the bedside. Option 4: Standardized report forms are handwritten, not spoken, and are used to communicate important information.

Which is true about colostomy irrigation? 1. Ileostomies do not need to be irrigated. 2. Irrigation is not used for colostomies distal to the descending colon. 3. Irrigation of a stoma is necessary in all colostomies. 4. The nurse should not allow the client to perform irrigation on his or her own stoma.

1 Rationales Option 1: Ileostomies have liquid, constant output, and they are not irrigated. Option 2: Irrigation is not used for stomas above the descending colon. Option 3: Not all ostomies require irrigation. Ostomies above the descending colon are not irrigated. Option 4: The goal of care of the stoma is to instruct the client to perform care for his or her own stoma.

With which client would be appropriate to ask closed questions? 1. One who is cognitively or developmentally impaired 2.One who has impaired speech 3.One who is unconscious 4.One who is from another culture

1 Rationales Option 1: It would be appropriate to ask closed (yes/no) questions to prevent client frustration. Option 2: With aphasia, speaking more slowly, not louder, is important. Closed questions are not necessary. Option 3: Speaking calmly and slowly is therapeutic for a client who is unconscious. Option 4: It is not necessary to ask closed questions to clients from a different culture. Obtaining a trained interpreter will facilitate accurate communication.

he nurse is caring for a client who underwent bowel surgery and returns to the floor with a nasogastric tube to low intermittent wall suction. The family questions the nurse as to why the client has the tube. What is the nurse's best response? 1. "The tube is in place to remove secretions until the bowels begin to work." 2. "The tube is in place in order for us to administer medications." 3. "The tube is in place to administer tube feedings until the bowel heals." 4. "The tube is in place to assess for gastrointestinal bleeding postoperatively."

1 Rationales Option 1: Peristalsis is slowed or may even stop when a client undergoes bowel surgery with anesthesia. The nasogastric tube is inserted to low intermittent wall suction to remove gastric secretions until peristalsis returns. Option 2: It would not benefit the client to receive medications via the nasogastric tube, as they would not be absorbed. Option 3: Tube feedings would not be administered, as the bowel has not healed. Total parenteral nutrition would be more appropriate. Option 4: Gastrointestinal (GI) bleeding can be determined by other means besides a nasogastric tube. The tube would not be placed to assess for this complication.

The nurse is caring for a client in the endoscopy recovery area after undergoing an esophagogastroduodenoscopy (EGD). The client asks for a sip of water. What should the nurse do first? 1. Determine if the gag reflex has returned. 2. Telephone the gastroenterologist for orders. 3. Review the electronic health record (EHR). 4.Inform the client that he or she is still NPO for 12 to 24 hours.

1 Rationales Option 1: The area of the back of the throat is numbed during the EGD. The nurse should assess for the presence of the gag reflex prior to giving a drink to the client. This will prevent aspiration. Option 2: The nurse need not contact the gastroenterologist for orders because there are standard post-EGD protocols. Option 3: The nurse would not review the EHR to determine the ability for the client to have a sip of water. Option 4: The nurse would not inform the client that he or she is NPO for 12 to 24 hours, as this is inaccurate information. The client would resume a light diet later in the day

Which part of the kidney is made up of millions of functional units called nephrons? 1. Cortex 2. Calyx 3. Medulla 4. Renal pelvis

1 Rationales Option 1: The cortex is the outer part of the kidney and contains millions of functional units called nephrons. Option 2: The calyx is the central part of the kidney and directs urine into the renal pelvis. Option 3: The medulla is the inner layer of the kidney, made up of collecting tubules. Option 4: The renal pelvis is the innermost layer of the kidney.

The nurse enters the room of a client lying in bed to discuss ostomy care. Which form of nonverbal language is most appropriate when speaking with the client? 1.Sit down at eye level with the client. 2.Cross your arms when listening to the client. 3.Avoid using touch when supporting the client. 4.Refrain from making eye contact with the client.

1 Rationales Option 1: The nurse should be at eye level when working with the client. This places the nurse equal to the client and not in an authoritative position. Option 2: In most cultures, crossing one's arms is a sign of being closed off and unapproachable. The nurse should maintain an open stance. Option 3: The nurse should use touch when appropriate to provide support to the client. This conveys a message of caring. Option 4: The nurse should always maintain eye contact when speaking with the client.

he nurse is discussing ways to treat functional incontinence with a group of older adults in a senior citizens center. Which intervention would be most appropriate for the nurse to include in the presentation? 1.Timed voiding 2.Kegel exercises 3.Straight catheterization 4.Pharmacological treatment

1 Rationales Option 1: The nurse would instruct the clients to use the bathroom to urinate every 2 to 3 hours. This alleviates the problem of not being able to get to the bathroom in time. Option 2: The nurse would instruct clients with stress incontinence, not functional incontinence, how to perform Kegel exercises. Option 3: The nurse would encourage a client with a spinal cord injury or neuromuscular disorder, not urinary incontinence, to perform straight catheterization to prevent urinary retention. Option 4: The nurse would discuss pharmacological treatment of urge incontinence with the client and health-care provider. These medications are not appropriate for functional incontinence.

What is the difference between denotation and intonation? 1. Denotation is the dictionary meaning of the words, whereas intonation is the tone of voice. 2. Denotation is the dictionary meaning, whereas intonation is the implied or emotional meaning. 3. Denotation is the tone of voice, whereas intonation is the dictionary meaning. 4. Denotation is the implied or emotional meaning, whereas intonation is the tone of voice.

1 Rationales Option 1: These are the correct definitions of denotation and intonation. Option 2: Denotation is the correct definition, but intonation is incorrect. Option 3: The denotation and intonations are both incorrect. Option 4: The intonation definition is correct, but the denotation definition is incorrect.

The nurse is working with parents of a client recently diagnosed with cystic fibrosis, and they tell the nurse they fear the child will not have a normal life. Which statement made by the nurse indicates the use of restating? 1."I understand your concern that your child may not live a normal life. More adults with cystic fibrosis have more normal lives as there are new treatments that prolong and improve quality of life." 2."When you tell me you are afraid of your child's disease, what aspect scares you the most?" 3."When you say you are worried about the disease, are you worried about the financial costs?" 4."What would you picture as a normal life for your child?"

1 Rationales Option 1: This statement indicates the nurse is using the technique of restating to validate the client's concerns. Option 2: When the nurse repeats what the client stated and asks more information, this is an example of clarifying. Option 3: This statement validates the client's fears, as it asks if the parents are concerned about the financial costs of the disease. Option 4: When the nurse asks the parents what they picture as normal for their child, it clarifies what their expectations are for the child.

A nurse is learning about various communication concepts and techniques. Which statement by the nurse is correct about intrapersonal communication? 1. An internal dialogue is known as self-talk. 2. Communication involves two or more people to accomplish a goal. 3. Communication involves more than two people who exchange ideas at the same time. 4. A unique form of group communication is when the speaker interacts with others to varying degrees.

1 A nurse is learning about various communication concepts and techniques. Which statement by the nurse is correct about intrapersonal communication? 1. An internal dialogue is known as self-talk. 2. Communication involves two or more people to accomplish a goal. 3. Communication involves more than two people who exchange ideas at the same time. 4. A unique form of group communication is when the speaker interacts with others to varying degrees.

Which health history information should be obtained before a nurse places an indwelling catheter? Select all that apply. 1. Any allergies 2. History of bladder surgery 3. History of heart disease 4. Any problems with constipation 5. Number of pregnancies

1 and 2 Rationales Option 1: Allergies to iodine and latex will require alterations to normal indwelling catheter insertion procedure. Option 2: History of bladder disease may require a smaller lumen catheter or alteration in the procedure. Option 3: A history of heart disease is not relevant to catheter insertion. Option 4: Constipation is not relevant to catheter insertion. Option 5: Number of pregnancies is not usually relevant to catheter insertion.

What should the nurse include in the post-procedure care for a client who underwent a cystoscopy? Select all that apply. 1.Monitor intake and output. 2.Assess color and clarity of urine. 3.Provide only clear liquids. 4.Obtain vital signs every 8 hours. 5.Instruct about the use of contrast dye.

1, 2 Rationales Option 1: The nurse would be responsible for monitoring intake and output after a client undergoes a cystoscopy. This ensures adequate urine flow after the procedure. Option 2: The nurse would assess the color and clarity of the urine. This would allow the nurse to detect complications from the procedure such as bleeding. Option 3: The client can resume the diet that was prescribed prior to the procedure. Option 4: Vital signs are obtained more frequently after a cystoscopy due to the use of sedation. Option 5: The nurse would explain about the use of contrast dye when a client has an intravenous pyelogram, not a cystoscopy.

Which structures are contained within a nephron? Select all that apply. 1. Collecting duct 2. Bowman's capsule 3. Ureters 4. Renal cortex 5. Filtrating tubules

1, 2 and 5 Rationales Option 1: A collecting duct is where filtrate is collected. Option 2: A Bowman's capsule is a double-walled hollow capsule that encloses a knotted ball of capillaries. Option 3: Ureters extend from the kidneys to the bladder. Option 4: The renal cortex is the outer layer of the kidney that contains the nephrons. Option 5: Filtrating tubules provide additional filtration of wastes.

What should the nurse include in the teaching for a client with an ileal conduit urinary diversion? Select all that apply. 1. Ensure the collection device fits snugly against skin. 2. Empty the ostomy bag frequently. 3. Apply lotion to the area if skin is excoriated. 4. Catheterize the reservoir several times a day. 5. Performing Credé's maneuver to empty the bladder.

1, 2, Rationales Option 1: A good snug fit prevents urine from leaking onto the skin. If this happens, it crystallizes and can cause skin irritation. Option 2: The client should be taught to empty the bag when it is about one-third full. This prevents the bag from becoming heavy and separating from the face plate. Option 3: Lotion should not be used on peristomal skin because it can irritate the skin. Option 4: A client with a continent urinary reservoir, not a urinary diversion, would catheterize the reservoir. Option 5: The nurse would instruct the client with a neobladder to perform the Credé's maneuver to empty bladder. This is not applicable for a client with a urinary diversion

The nurse is communicating with an elderly client, but it appears the client is not understanding what the nurse is explaining. What should the nurse assess for in the elderly client to determine communication barriers? Select All That Apply. 1. Assess for level of orientation 2. Assess for visual disturbances 3. Assess for hearing impairment 4. Assess for difficulty with ambulation 5. Assess for changes in the taste of food

1, 2, 3 Rationales Option 1: Cognitive changes such as dementia can happen in elderly clients. Therefore, the nurse should assess the client's level of orientation. Option 2: Visual changes can occur during the aging process. The nurse would use the interview to determine if the client is experiencing any changes in vision. Option 3: Elderly clients may develop sensory changes such as hearing loss. Option 4: The nurse should assess for changes in ambulation when assessing the client's mobility. However, this is not an aspect to assess during an interview. Option 5: Although taste does change as people age, this does not impact communication with an elderly client.

Which factors place female clients at higher risk for urinary tract infections? Select all that apply. 1.Pregnancy 2.Menopause 3.Sexual activity 4.Prostate enlargement 5.Longer urethral length

1, 2, 3 Rationales Option 1: Pregnancy can increase a female client's risk for urinary tract infections due to pressure on the bladder and hormonal changes. Option 2: Menopause causes decreased normal flora as well as drying of the vaginal mucosa. These can cause urinary tract infections. Option 3: Perineal pathogens can enter the urinary tract during sexual intercourse, which can cause urinary tract infections. Option 4: Prostate enlargement occurs in men, not women. Option 5: Men have a longer urethral length than women. The shorter urethra places the female at higher risk for urinary tract infections.

The parents of a 2-year-old child voice concern to the nurse that they are not able to toilet train the child yet. Which factors should the nurse explain to the parents that affect toilet training? Select all that apply. 1.The child must be able to sense the urge to void. 2.The child must be able to remove his or her clothes. 3.The child must be able to voice the need to urinate. 4.The child must be able to completely wipe from front to back. 5.The child must be able to balance himself or herself on the toilet.

1, 2, 3, Rationales Option 1: In order to obtain bladder control, the toddler must be able to sense the urge to urinate. Option 2: The child must be able to remove his or her clothes in order to be toilet trained. Option 3: In order to be toilet trained, the child must be able to verbalize the need to urinate. Option 4: The child does not need to be able to wipe from front to back, as parents and caregivers can help with this. Option 5: The child can be toilet trained using a smaller potty chair until he or she is big enough to sit on a toilet.

The home health nurse just removed an indwelling urinary catheter from a client per the health-care provider's order. Which instructions should the nurse provide the client? Select all that apply. 1. Report any pain or burning upon urination. 2. Increase oral fluid intake to promote urine production. 3. Contact the health-care provider if unable to urinate 8 hours after catheter removal. 4. Notify the health-care provider after the first void with color and amount of urine. 5. Discard the first urine sample after removing the catheter and then collect the urine in a jug for the next 24 hours.

1, 2, 3, Rationales Option 1: The nurse would instruct the client to report any pain or burning upon urination. Indwelling urinary catheters can increase the risk for infections, and the client should report this finding. Option 2: The nurse should instruct the client to drink lots of fluids after the catheter is removed. This will help facilitate urine production. Option 3: The home health nurse should instruct the client to notify the health-care provider if he or she does not urinate 8 hours after the catheter is removed. This may require reinsertion of the catheter if the client is retaining urine. Option 4: The nurse would not instruct the client to notify the health-care provider after the first void. This is an expected outcome and does not warrant health-care provider notification. Option 5: The nurse would instruct a client to discard the first urine sample and collect urine for the next 24 hours if obtaining urine for a 24-hour urine test for protein or creatinine clearance. This is not done after removal of an indwelling urinary catheter.

The nurse educator is preparing a class for new graduate nurses about barriers to therapeutic communication. What do the barriers include? Select all that apply. 1.Asking too many questions 2.Asking "why" 3.Changing the subject inappropriately 4.Offering advice 5.Providing realistic reassurance 6.Providing false reassurance

1, 2, 3, 4, 6 Rationales Option 1: This is a barrier to therapeutic communication, especially closed questions. The client may interpret this as insensitive or rushing. Option 2: Starting a question with "why" may make the client shut down or become defensive. Option 3: The nurse should not change the subject but focus on what the client is stating. Option 4: Avoid statements like, "If I were you" or "You should do this or that." Clients may interpret this as judgmental. Option 5: This provides empathy and eases concern. Option 6: Nurses should not tell clients and/or family members that everything will be fine because the nurse cannot guarantee that.

What are the characteristics of a successful group? Select all that apply. 1. Shared leadership and responsibility 2. Cohesive climate 3. Mutual trust 4. Vaguely defined purpose 5.Shared set of guidelines for functioning 6.Willingness to change what is not working

1, 2, 3, 5, 6 1. Shared leadership and responsibility 2. Cohesive climate 3. Mutual trust 4. Vaguely defined purpose 5. Shared set of guidelines for functioning 6. Willingness to change what is not working

Question 9. The nurse is educating unlicensed nursing assistive personnel (NAP) about recording output for a client. What fluids should the nurse include in the output for accuracy? Select all that apply. 1.Urine 2.Emesis 3.Diarrhea 4.Nasal drainage 5.Intravenous fluids 6.Nasogastric drainage

1, 2, 3, 6 Rationales Option 1: Urine is a body fluid that should be recorded in the client's output. Option 2: Body fluids that should be recorded in the output include any emesis the client has. Option 3: Diarrhea needs to be charted in the output in the client's medical record. Option 4: Nasal drainage is not calculated, nor is it recorded in the output. Option 5: Intravenous fluids would be recorded under the intake section, not the output. Option 6: Nasogastric drainage is recorded in the output.

The nurse is educating a group of older adults about constipation. Which gerontological changes should the nurse include in the session? Select all that apply. 1. Diminished mobility 2. Lowered fluid intake 3. Decreased peristalsis 4. Changes in fiber intake 5. Increased sphincter control 6. Improved smooth muscle tone

1, 2, 3, and 4 Rationales Option 1: As people become older, mobility diminishes and can lead to constipation. Option 2: Older clients decrease fluid intake due to a lowered thirst sensation. This can cause constipation. Option 3: Peristalsis decreases with aging and can be a factor for constipation. Option 4: Decreased fiber intake is a risk factor found to cause constipation. Option 5: As a client ages, the sphincter control decreases, which can lead to constipation. It does not increase. Option 6: The smooth muscles of the colon have lesser tone, which contributes to constipation. The tone is not improved.

What should the nurse include to promote effective communication with the health-care team? Select All That Apply. 1.Report any concerns to the proper person. 2.Discuss any clinical errors with coworkers. 3.Point out individual errors in team meetings. 4.Question the health-care provider regarding unclear orders. 5.Speak about the issues in a timid manner with the appropriate person.

1, 2, 4 Rationales Option 1: The nurse should speak up and report any concerns. Option 2: It is important for the nurse to be assertive and discuss clinical errors or poor judgment with coworkers. Option 3: It is not appropriate to point out one person's errors in front of the entire health-care team. These matters should be discussed privately. Option 4: The nurse should be assertive and question any confusing orders written that do not make sense. Option 5: The nurse should be assertive, not timid, when speaking about issues.

Which interventions should the nurse incorporate into the plan of care for a client with a new ostomy that is having difficulty coping with the body change? Select all that apply. 1. Show acceptance when working with the stoma. 2. Explain to the client that his or her sexual relations would not change. 3. Instruct the client that a dressing can be placed over the ostomy during sexual relations. 4. Provide information regarding support groups available for clients with ostomies. 5. Allow the client to ventilate feelings about having a new colostomy and how it changes his or her life. 6. Show the client how to take care of the ostomy, including changing the bag and wafer.

1, 2, 4, 5 Rationales Option 1: When the nurse is working with the client who has a stoma, the nurse should discuss care of the stoma naturally without feeling disgusted. Option 2: The nurse can discuss sexual intimacy with the client and explain that his or her sex life should remain the same with an ostomy. Option 3: The nurse would not instruct the nurse to cover up the ostomy during sexual relations. This leads the client to believe the stoma is something that causes shame. Option 4: The nurse can share information about ostomy support groups in the area. Option 5: The nurse should allow the client to express his or her feelings about the new colostomy and its impact on daily life. Option 6: The nurse would show the client how to independently manage the colostomy; however, this does not help with body image.

Which symptoms characterize flatulence? Select all that apply. 1.Cramping 2.Abdominal distention 3.Rectal bleeding 4.Heartburn sensation 5.Sharp abdominal discomfort

1, 2, 5 Rationales Option 1: Flatulence is usually accompanied by uncomfortable cramping. Option 2: A feeling of bloating and distention usually accompanies flatulence. Option 3: Flatulence is not usually associated with rectal bleeding. Option 4: Heartburn sensation is not characteristic of flatulence. Option 5: Sharp abdominal pain is a symptom of flatulence.

A client who had an ileostomy returns to the clinic and informs the nurse he or she is having difficulty with an odor coming from the ostomy bag. Which foods should the nurse instruct the client to avoid in order to decrease ostomy odor? Select all that apply. 1. Beer 2. Asparagus 3. Chocolate 4. Cucumbers 5. Romaine lettuce

1, 2, and 4 Rationales Option 1: Beer consumption can lead to odor from the ostomy bag. This should be limited or eliminated from the client's intake. Option 2: Asparagus is an odor-producing food and should be restricted in the client's diet. Option 3: Chocolate does not lead to odor from the ostomy bag. It does not need to be limited in the diet. Option 4: Cucumbers can produce odor, so these should be eliminated. Option 5: Romaine lettuce is not an odor-producing food and can be consumed by the client.

Which environmental factors should the nurse control when interviewing a client? Select All That Apply. 1. Noise 2. Odors 3. Presence of family 4. Comfortable temperature 5. Open public environment

1, 2, and 4 Rationales Option 1: The nurse should schedule the interview to take place in a quiet area. Option 2: Hospital areas can have many unpleasant smells. The nurse should make sure the interview is in an area free of odors. Option 3: The presence of family members is not an environmental factor. Family members should not be included in an interview with a client unless the client gives permission. Option 4: The nurse should ensure the interview room is set at a comfortable temperature so the client is not too hot or cold. Option 5: The nurse should ensure there is privacy for the interview. This should take place in an area with a door that closes.

Which are common disorders that are primary causes of bowel function? Select all that apply. 1.Food allergies 2.Diverticulosis 3.Pneumonia 4.Seasonal allergies 5.Food intolerance

1, 2, and 5 Rationales Option 1: A food allergy is a true immune system response prompted by the body in response to an allergenic food. Option 2: Diverticulosis occurs when the body must move highly compacted stool over time, enlarging the surrounding muscles. This causes them to balloon out, and fecal material is trapped in the swollen areas, which become infected. Option 3: Pneumonia can ultimately lead to alterations in intake which could affect elimination, but it is not a primary cause. Option 4: Seasonal allergies are not associated with bowel elimination disorders. Option 5: Food intolerance is specifically linked to GI symptoms, as opposed to a food allergy, which triggers the immune system.

Which actions occur to blood as it moves through the peritubular capillaries? Select all that apply. 1. Removes ammonia from blood 2. Hydrogen ions secreted to help maintain normal blood pH 3. Antidiuretic hormone produced 4. Aldosterone secreted 5. Removes creatinine from the blood

1, 2, and 5 Rationales Option 1: As blood moves through peritubular capillaries, waste products, including ammonia, are removed. Option 2: Hydrogen ions are secreted by the peritubular capillaries to normalize blood pH. Option 3: Antidiuretic hormone is produced by the posterior pituitary gland. Option 4: Aldosterone is secreted by the posterior pituitary gland. Option 5: Waste products are removed from blood as it moves through the peritubular capillaries.

Which physiological factors can place an 83-year-old client at risk for acute kidney injury? Select all that apply. 1.Decline in glomerular function 2.Loss of urinary sphincter control 3.Arteriosclerotic blood vessel changes 4.Decreased abdominal muscle control 5.Consumption of large quantities of caffeine

1, 3 Rationales Option 1: By the time a client is 80-years-old, only about two-thirds of the nephrons function. This places the client at risk for acute kidney injury. Option 2: Loss of urinary sphincter control leads to urinary incontinence, not acute kidney injury. Option 3: Arteriosclerosis occurs with age and this decreases blood flow to the kidneys. Option 4: Clients, especially females, are at higher risk for urinary incontinence when abdominal muscle control decreases. This does not cause acute kidney injury. Option 5: Caffeine is a diuretic and increases urine production. This does not place the client at risk for acute kidney injury.

The nurse is providing discharge teaching for a client who will be taking a loop diuretic. What should the nurse include in the teaching? Select all that apply. 1. Change positions slowly. 2. Stay out of direct sunlight. 3. Report any muscle weakness. 4. Notify the health-care provider of any rash. 5. Signs and symptoms of high potassium levels.

1, 3, 4 Rationales Option 1: Diuretics have a side effect of hypotension and dizziness. Therefore, the nurse should teach the client to change positions slowly. Option 2: The nurse would instruct the client who is taking a thiazide diuretic, not a loop diuretic, to stay out of the direct sunlight. Option 3: The nurse would instruct the client to report any muscle weakness, as this can be a major complication from diuretic use. Option 4: A rash indicates a possible allergic reaction and this should be reported. Option 5: The nurse would instruct the client about the signs and symptoms of low potassium levels as this is a side effect of loop diuretics.

Which are ways the nurse can promote regular defecation for clients? Select all that apply. 1. Provide privacy. 2. Remind the client that constipation could occur if he or she does not defecate regularly. 3. Take a matter-of-fact straightforward approach. 4. Control odors to prevent embarrassment. 5. Accompany the client and provide encouragement while he or she is attempting defecation.

1, 3, 4 Rationales Option 1: Providing privacy can help a client relax and feel more comfortable during defecation. Option 2: Putting pressure on the client to defecate regularly could have the opposite effect, as it could cause stress and anxiety. Option 3: If the nurse conveys comfort with this aspect of care, the client may be less self-conscious. Option 4: Clients may be embarrassed by the odors, and the nurse can assist by providing odor control. Option 5: Speaking with the client and accompanying him or her during defecation is not respectful of privacy and could add to stress and anxiety.

In which ways can surgery or procedures contribute to sluggish bowel elimination? Select all that apply. 1. Anesthesia 2. Increased IV fluids 3. Stress 4. Decreased mobility 5. Manipulation of the bowel

1, 3, 4, 5 Rationales Option 1: General anesthesia and sedating agents slow bowel motility. Option 2: Increased IV fluids do not contribute to sluggish bowel elimination. Option 3: Surgery is a stressful event, which stimulates the autonomic nervous system and slows peristalsis. Option 4: Decreased mobility due to pain or other restrictions can lead to decreased bowel function. Option 5: Surgery on the abdomen or a section of bowel may result in paralysis of part of the bowel, or paralytic ileus.

Which interventions should the nurse instruct the client to perform to decrease the incidence of urinary incontinence? Select all that apply. 1. Eliminate caffeine from the diet. 2.Limit the intake of fluids. 3. Stop smoking. 4. Lose weight. 5. Increase the use of artificial sweeteners.

1, 3, and 4 Rationales Option 1: Caffeine is an irritant to the bladder mucosa. Therefore, it should be eliminated from the diet. Option 2: The nurse would not instruct the client to limit fluid intake. This can lead to acute kidney injury, infection, and dehydration. Option 3: Smoking has been linked to urinary incontinence as well as other health problems. Option 4: If the client is overweight, weight loss has been found to decrease the incidence of urinary incontinence. Option 5: The client should decrease the use of artificial sweeteners, as these can irritate the bladder mucosa and cause urinary incontinence.

A nurse is assessing a urostomy on a client. She should be most concerned about which findings? Select all that apply. 1. Sloughing of skin 2. Moisture 3. Skin breakdown 4. Encrustation 5. Red in color

1, 3, and 4 Rationales Option 1: Sloughing of skin could be the result of severe skin irritation. Option 2: A normal urostomy site is moist and shiny. Option 3: Skin breakdown can occur if urine is left on the skin for a period of time. Option 4: Encrustation is a risk for a localized infection in a urostomy. Option 5: A normal urostomy is red in color.

Which are urinary symptoms that may occur as a result of the aging process? Select all that apply. 1.Leakage of urine 2.Decreased frequency of urination 3.Decreased volume of urine 4.Nocturnal frequency of urine 5.Bladder infections

1, 4, 5 Rationales Option 1: Leakage of urine related to loss of pelvic muscle tone can occur. Option 2: Decreased frequency of urination is not associated with aging. Option 3: Decreased volume of urine produced is not associated with aging. Option 4: Nocturnal frequency of urine may occur as a result of incomplete bladder emptying. Option 5: Bladder infections can occur as a result of incomplete bladder emptying.

Verbal communication is a key process for caring for clients. Verbal communication consists of which factors? Select all that apply. 1. Vocabulary 2. Pacing and rhythm 3. Facial expressions 4. Timing and relevance 5. Posture and gait 6.Touch

1,2 and 4 Rationales Option 1: Nurses must be able to communicate information based on lay terms and not medical jargon. Option 2: Pacing and rhythm are important to keep the receiver's attention. Option 3: This is a nonverbal communication technique. Option 4: Nurses should assess if the client is ready to communicate (i.e., if the client is in pain, assess that need first). Option 5: This is a nonverbal communication technique that clients will observe when communicating. Option 6: This is a nonverbal communication technique and conveys care, concern, and hope. Be aware that some people do not want to be touched, so assess first.

Which instructions should the nurse provide a client to prepare for a colonoscopy? Select all that apply. 1.Take laxatives as prescribed for the bowel prep. 2.Do not eat or drink anything after midnight prior to the test. 3.Have someone drive you home from the test due to sedation used in the procedure. 4.Refrain from eating after the procedure until your gag reflex returns. 5.Gargle with saline mouthwashes after the procedure.

1,2, 3 Rationales Option 1: The nurse would instruct the client to take the laxatives as prescribed to totally evacuate the bowel of stool. This allows the health-care provider to view the colon. Option 2: The client would be NPO after midnight the night prior to the test. Option 3: Since sedation is used during a colonoscopy, arrangements should be made to have a driver take the client home after the procedure. Option 4: The nurse would instruct a client who underwent an esophagogastroduodenoscopy to wait until the gag reflex returns prior to eating. Option 5: A client who had an esophagogastroduodenoscopy would need to rinse and gargle with saline or salt water to decrease irritation from the tube being inserted down the throat.

What clinical manifestations might a nurse expect to see if a client has impaired renal function? Select all that apply. 1. High blood pressure 2. Altered mental status 3.Increased urine production 4. Fluid retention 5. Decreased heart rate

1,2, and 4 Rationales Option 1: When the body is unable to rid itself of sodium, fluid is retained and blood pressure increases. Option 2: When ammonia levels increase, lethargy and confusion occur as a result. Option 3: Urine production will not increase with impaired renal function. Option 4: When filtration is impaired, the body retains fluid. Option 5: Heart rate is likely to increase as a result of increased cardiac workload from fluid volume increase.

Which interventions should the nurse include when performing a procedure within the client's intimate space? Select All That Apply. 1. Explain to the client about the procedure. 2. Inform the client when the nurse will touch the client. 3. Ask the client for permission prior to moving into the intimate space. 4. Keep 18 inches to 4 feet of intimate space when providing care. 5. Acknowledge the client may be uncomfortable when the nurse is within the client's intimate space.

1,2, and 5 Rationales Option 1: The nurse first explains to the client what the nurse will do prior to moving into a client's intimate space. Option 2: The nurse should inform the client when the touch will occur. This can allow the client to prepare for the procedure. Option 3: For some procedures that must be performed, touch is not optional. Therefore, the nurse does not ask for permission first prior to the touch. Option 4: Intimate space, or intimate distance, is up to 18 inches. Personal distance goes from 18 inches up to 4 feet. Option 5: The nurse should acknowledge the client may be uneasy about the nurse being in his or her intimate space.

Therapeutic communication requires the use of self in order to provide an effective relationship with the client. What are the characteristics of therapeutic communication? Select all that apply. 1. Empathy 2. Respect 3. Non-confrontation 4. Genuineness 5. Concreteness 6. Sympathy

1,2,4,5 Rationales Option 1: Empathy is one of the five characteristics and allows vulnerability between the nurse and client for optimal health. Option 2: Respect between the client and nurse provides an environment that supports the needs of the client with flexibility. Option 3: Confrontation is a characteristic of therapeutic communication in order to develop an open dialogue with the client. Option 4: Clients have the right to receive information that is truthful. Option 5: Nurses should communicate with direct responses to the client's questions that are meaningful to the client. Option 6: Feeling sorry or sympathetic to a client is a one-way communication and does not allow for an exchange of information.

Which communication technique allows the nurse to provide input while discussing goals at the client's bedside? 1. Client rounding 2. Audio recording 3. Care conference forms 4. Standardized report forms

1. Rationales Option 1: Client rounding is a collaborative approach that allows nurses and health-care providers to equally discuss the plan of treatment and client goals at the bedside. Option 2: The nurse uses a recording device to verbalize end-of-shift reports about the client in the break room, not at the client's bedside. Option 3: A client care conference is usually held in a conference room and has representation from all involved in the client's care. This is not done at the bedside. Option 4: Standardized report forms are handwritten, not spoken, and are used to communicate important information.

Which assessment finding made by the nurse confirms a client has a biliary obstruction? 1.Red stool 2.White stool 3.Brown stool 4.Yellow stool

2 Rationales Option 1: A red color in the stool indicates blood. This would not be noted in a client with a biliary obstruction. Option 2: A white or clay-colored stool indicates an obstruction in the biliary tract because bile cannot drain into the small intestine. Bile gives feces its brown color. Option 3: Brown is a normal fecal color. Option 4: Yellow stool is found in infants who are breastfed. This does not indicate a biliary obstruction.

A nurse is caring for an elderly client who has nearly fallen twice while getting out of bed to go to the bathroom. The nurse has instructed the client not to get up without assistance. The client tells the nurse about feeling a need to get to the bathroom when the urge to void occurs and feeling a need to rush. Which strategy should the nurse utilize to minimize the client's risk of falling? 1.Obtain an order for an indwelling catheter. 2.Check on the client every 2 hours and offer toileting assistance. 3.Require that a family member stay with the client. 4.Obtain an order for restraints to prevent injury.

2 Rationales Option 1: An indwelling catheter has a risk of injury or infection. Option 2: Offering frequent toileting can help the client with voiding before the bladder is full. Option 3: Requiring a family member to stay may not be possible, and it may not decrease the risk of falling. Option 4: Restraints should only be used as a last resort, and never to prevent falling.

Which is the result of the passage of stool through the colon being slowed? 1. Diarrhea 2. Constipation 3. Distention 4. Ileus

2 Rationales Option 1: Diarrhea is the result of stool passing through the colon quickly, not allowing enough water absorption. Option 2: Constipation occurs when stool passage through the colon is slowed, allowing more water absorption to result in a hardened stool. Option 3: Distention may occur with a variety of abnormal patterns of bowel elimination. Option 4: A paralytic ileus is the result of a portion of the colon being paralyzed.

Which condition in older men can result in impaired flow of urine from the bladder into the urethra? 1. Renal calculi 2. Prostatic hypertrophy 3. Cardiovascular disorders 4. Stroke

2 Rationales Option 1: Renal calculi can impair urinary elimination, but the mechanism is not from the bladder to the urethra. Option 2: Prostatic hypertrophy is an enlarged prostate, and it can impair flow of urine out of the bladder. Option 3: Cardiovascular disorders can interfere with normal renal function, but the mechanism is not the outflow of urine from the bladder. Option 4: A stroke can lead to urinary incontinence, not impaired urine outflow.

Which lab test can be done at the bedside and requires the least amount of stool specimen? 1. Testing for parasites 2. Fecal occult blood test 3. Clostridium difficile testing 4. Testing for infectious processes

2 Rationales Option 1: Testing for parasites usually requires 2.5 cm of formed stool. Option 2: Fecal occult blood testing requires only a small amount of stool and may be done at the bedside in some facilities. Option 3: Clostridium difficile testing requires 20 to 30 mL of liquid stool. Option 4: Testing for infection in the stool requires approximately 2.5 cm of formed stool or 20 to 30 mL of liquid stool.

Which communication element is being used by the nurse when he or she informs the charge nurse of an inability to handle a new admission? 1.Channel 2.Message 3.Encoding 4.Feedback

2 Rationales Option 1: The channel is the way the message is sent. The focus of this conversation is not the channel. Option 2: The message is what is being stated. The important aspect of this communication is that the nurse cannot handle more work. Option 3: Encoding is the way a message is sent. This includes verbal and nonverbal communication. This is not an example of encoding. Option 4: Feedback is what the receiver gives to the original sender of the message. No feedback has been given to the nurse yet.

The registered nurse is observing a nursing student administer a soapsuds enema to a client. Which action made by the student nurse requires correction? 1. Placing the client in the left side-lying position 2.Holding the container 45 to 60 cm above the hips 3.Lubricating the tip of the enema tubing generously 4. Inserting the tip of the enema tubing approximately 7 to 10 cm

2 Rationales Option 1: The client should be placed in the left side-lying (Sims) position. This allows the enema solution to follow the natural flow of the colon. Option 2: The student nurse should hold the enema container 30 to 45 cm above the hips. If the bag is held too high, the solution infuses too fast and can cause cramping. Option 3: The tube should be generously lubricated to facilitate easy passage of the enema tubing and minimize the risk of rectal trauma. Option 4: The tube should be inserted approximately 7 to 10 cm into the rectum. This allows the fluid to enter the colon.

A nurse is caring for a client who had a stroke 2 days ago and is aphasic. The client's spouse is visiting during lunchtime. Who should the nurse communicate with? 1. The client's spouse, who can answer the questions for the client 2. The client, who is learning to use a white board for communicating needs and wants 3. Neither the client or spouse, as it is during lunchtime 4. Both the client and spouse, but the nurse should be looking at the spouse

2 Rationales Option 1: The nurse should address the client at all times. Option 2: The nurse should maintain client independence and maximize strengths. Option 3: There is no need to avoid communicating with the client and spouse unless they requested privacy. Option 4: Questions can be addressed to both parties, but the nurse should look at the client when speaking.

A client with a new ileostomy asks the nurse why he or she cannot irrigate the ostomy like others in the ostomy support group. What would be the nurse's best response? 1."This is the way your health-care provider prefers his or her ostomies to be managed." 2."The other clients may have colostomies that can be irrigated due to the stool being solid." 3."Why would you want to perform irrigation? It can be so messy. It is easier to use the ostomy bag." 4."Irrigations are very complex and can be difficult to manage. Those clients may have had their ostomies for many years."

2 Rationales Option 1: This does not provide the client information as to why the client cannot irrigate the ostomy. This is not the nurse's best response. Option 2: Colostomies can be irrigated due to the stool being solid. Ileostomies cannot be regulated to evacuate with irrigation due to the stool being liquid. Option 3: "Why" statements are not therapeutic communication and can place the client in a defensive mode. This is not the nurse's best response. Option 4: This statement is not therapeutic because it implies that the client is not intelligent enough to handle the irrigation.

c is a standardized communication tool utilized between nurses and other health-care providers when there is a change in a client's condition. Which statement presents the background information? 1. "This is Kate and I am taking care of Mrs. Smith who is on Wesson 424A. Mrs. Smith is experiencing shortness of breath." 2. "Mrs. Smith has a respiratory rate of 36 breaths per minute, her oxygen saturation is 91% on room air, and she has crackles in the left lower lung." 3."I think Mrs. Smith may be going into heart failure." 4."I think Mrs. Smith needs oxygen via cannula, a chest x-ray, and Lasix STAT."

2 Rationales Option 1: This information is the Situation description. Option 2: This is the Background part of the tool. Option 3: This is the Assessment part of the tool. Option 4: This is the nurse's Recommendation to the provider.

Which is a definition of a therapeutic relationship? 1.The hallmark of nursing practice based on meaningful communication 2. A relationship that focuses on improving the health of the client, whether an individual or community 3. Client-centered care directed at achieving client goals 4. A nurse-client relationship that hinges on evidence-based practice

2 Rationales Option 1: This is Benner's definition of caring. Option 2: This is the correct definition of a therapeutic relationship. Option 3: This is the definition of therapeutic communication that is just as important as the relationship. Option 4: Evidence-based practice is important to therapeutic relationships but is not part of the definition.

The health-care team is meeting about changes being made regarding communication. Which statement is made by the nurse in an appropriate manner to broach an issue on the unit? 1. "It would be nice if the night shift did what they were supposed to do and not leave the work behind." 2. "I find it difficult when it takes an hour for orders to show up in the computer because it delays treatments for clients." 3. "We have a predicament on this unit with the pharmacy taking over an hour to verify all medication orders for the clients." 4. "I'm not sure, but it seems to me that the therapy department leaves the clients' rooms in disarray and this needs to change."

2 Rationales Option 1: This is an inappropriate statement to make, as it is points blame at others instead of looking at the problem. Option 2: When the nurse uses an "I" statement, it demonstrates how the issue impacts processes. It does not point blame at others. Option 3: The nurse is blaming the pharmacy for taking a long time to verify medication orders. The best solution is to bring pharmacy staff to the meeting and ask what is the best way to handle the process. Option 4: When discussing a problem, the nurse should be assertive and confident and not begin with timid statements.

The diabetic nurse educator is meeting a new client recently diagnosed with type 2 diabetes mellitus. Which statements are accurate about what this nurse will accomplish during the orientation phase? Select All That Apply. 1. The nurse gathers information about the client from the primary health-care provider. 2. The nurse explains that information will be shared with the primary health-care provider. 3. The nurse establishes a level of trust with the client by providing the client with accurate information. 4. The nurse informs the client about consequences of noncompliance with the treatment regimen. 5. The nurse and the client set mutually agreed-upon goals that meet the client's needs to manage his or her diabetes.

2 and 3 Rationales Option 1: The nurse obtains client information from the primary health-care provider in the preorientation phase. Option 2: It is important for the nurse to inform the client that he or she must report information back to the primary health-care provider who manages the client's health. Option 3: One of the goals of the orientation phase is to establish a level of trust with the client. Option 4: During the working phase, the nurse will provide the client with information regarding complications of uncontrolled diabetes mellitus. Option 5: Goals for treatment are established in the working phase.

Which behaviors should the nurse include when actively listening to a client? Select All That Apply. 1. Look at his or her watch. 2. Focus on nonverbal behaviors. 3.Face the client and lean in. 4.Type in the medical record when speaking. 5.Sit at the eye level of the client.

2, 3 and 5 Rationales Option 1: The nurse should not look at his or her watch, as this may make the client feel the nurse does not have enough time to listen. Option 2: The nurse should pay attention to nonverbal behaviors that are displayed by the client. This is especially true when the nonverbal communication does not match what the client is saying. Option 3: The nurse should face the client and lean in to pay attention when the client is talking. Option 4: The nurse should refrain from multitasking by typing and speaking at the same time. This shows the client that the nurse is not interested in what the client has to say. Option 5: The nurse should sit down at eye level when talking to the client. This does not make the nurse appear superior to the client.

A client asks the nurse which foods would help to consume 25 to 30 grams of fiber per day. Which foods should the nurse instruct the client to include in the diet? Select all that apply. 1. Pasta 2. Popcorn 3. Dried beans 4. Applesauce 5. Raw vegetables 6. Whole-grain breads

2, 3, 5, and 6 Rationales Option 1: It is not unhealthy to consume pasta; however, pasta is a carbohydrate that is not high in fiber content. Option 2: Popcorn is high in fiber and can be included to meet dietary fiber needs. Option 3: Dried beans and other legumes are a good source of fiber to include in the diet. Option 4: Applesauce is low in fiber content. It is a healthy food, but it is not high in fiber. Option 5: The client should include raw vegetables to help increase fiber in the diet. Option 6: Whole grains are an excellent source of dietary fiber to consume in the diet.

Which are common gastrointestinal symptoms suggestive of food allergy? Select all that apply. 1. Nausea 2. Rash around the anus 3. Excessive gas 4. Intestinal bleeding 5. Severe vomiting

2, 3, and 4 Rationales Option 1: Nausea is not usually an indicator of food allergy. Option 2: A rash around the anus is suggestive of food allergy, as the immune system responds to the allergen. Option 3: Excessive gas is an indicator of food allergy. Option 4: Intestinal bleeding is often seen in true food allergies. Option 5: Severe vomiting is an indicator of food poisoning rather than allergy.

Which techniques are barriers to communication with clients? Select All That Apply. 1. Allowing silence 2. Expressing approval 3. Providing false hope 4. Asking "why" questions 5. Interpreting body language

2, 3, and 4 Rationales Option 1: On occasion, silence is therapeutic when a client has been crying or needs a minute to think for the answer. Option 2: It is inappropriate for the nurse to give approval or disapproval for decisions made. The nurse should allow the client to make the decision that works best for the client. Option 3: The nurse should not make statements that give the client false hope that things will be better when the information is not true. Option 4: Questions that ask the client why he or she made a choice are judgmental and may make the client defensive. Option 5: The nurse should interpret the client's body language, as this can provide information about the client. This can include nervous habits or eye rolling.

The nurse is caring for a client with diarrhea related to a virus. According to the BRAT diet, which foods should the nurse instruct the client to include in the diet? Select all that apply. 1. Tea 2. Rice 3. Toast 4. Raisins 5. Asparagus 6. Applesauce

2, 3, and 6 Rationales Option 1: Although the fluids from tea may help prevent dehydration, it is not included in the BRAT diet. Option 2: Rice is included in the BRAT diet because it slows down gastrointestinal motility. Option 3: Dry toast is a food in the BRAT diet. It decreases gastrointestinal motility. Option 4: Raisins are very high in fiber and would be contraindicated in the BRAT diet. Option 5: Asparagus is not included in the BRAT diet. It contains fiber and may worsen diarrhea. Option 6: Applesauce is a food included in the BRAT diet and should be consumed to decrease gastrointestinal motility.2

A client presents to the emergency room passing bright red blood from the rectum. The health-care provider determines the client has bleeding hemorrhoids. Which causative factors should the nurse ask the client about? Select all that apply. 1. Anorexia nervosa 2. Chronic constipation 3. End stage renal disease 4. Prolonged sitting on the job 5. Upper gastrointestinal bleeding

2, 4 Rationales Option 1: Anorexia nervosa may cause other gastrointestinal complications, but it does not lead to bleeding hemorrhoids. Option 2: Chronic retention of fecal matter such as constipation can lead to bleeding hemorrhoids. Option 3: A client with end-stage liver disease, not renal disease, is at risk for bleeding hemorrhoids. Option 4: Prolonged sitting can place pressure on the blood vessels in the anal canal and cause bleeding hemorrhoids. Option 5: A client with an upper gastrointestinal bleeding will have blood in the emesis, not rectally.

Which are functions of the colon? Select all that apply. 1. Lipid digestion 2. Water absorption 3. Protein absorption 4. Vitamin absorption 5. Facilitate stool passage

2, 4 and 5 Rationales Option 1: Lipid digestion takes place in the small intestine, not the colon. Option 2: The colon is responsible for water absorption. Option 3: Proteins are absorbed in the small intestine. It does not occur in the colon. Option 4: Vitamin K and B vitamins are absorbed in the colon. Option 5: Stool passage is a main function of the colon.

The nurse is reviewing the laboratory data for a client admitted with acute kidney injury. Which values would the nurse expect to see elevated? Select all that apply. 1. Sodium 2. Creatinine 3. Red blood cells (RBC) 4. Blood urea nitrogen (BUN) 5. Glomerular filtration rate (GFR)

2, 4, Rationales Option 1: The sodium level is decreased in acute kidney injury due to excess fluid retention. Option 2: The creatinine level would be increased in a client with acute kidney injury, as the kidney cannot filter nitrogenous waste products. Option 3: The RBC would be decreased. The kidneys produce erythropoietin, which is essential for making red blood cells. If the client has acute kidney injury, erythropoietin production decreases. Option 4: The BUN is increased due to a buildup of nitrogenous waste products that happens in acute kidney injury. Option 5: The GFR decreases in acute kidney injury, as the kidney cannot adequately filter the blood.

A client with irritable bowel syndrome reports excess gas after meals. Which foods should the nurse instruct the client to avoid in the diet to decrease gas production? Select All That Apply. 1.Pasta 2.Beans 3.Yogurt 4.Onions 5.Broccoli

2, 4, 5 Rationales Option 1: Pasta slows peristalsis and does not contribute to gas production. Option 2: Beans are gas-forming foods. The nurse should instruct the client to avoid beans. Option 3: Yogurt can help stimulate peristalsis and replace normal intestinal flora. This food would not decrease gas production. Option 4: Onions are foods that increase gas production and should be eliminated from the diet. Option 5: Broccoli is a food that causes increased gas formation. Therefore, the client should eliminate this from the diet.

Which functions of the kidney are considered secondary functions? Select all that apply. 1.Acid-base balance 2.Renin production 3.Water reabsorption 4.Vitamin D activation 5.Erythropoietin secretion

2, 4, and 5 Rationales Option 1: Acid-base balance is a primary function of the kidney. It does this by regulating hydrogen ion excretion. Option 2: Renin is excreted by the kidneys in response to hypotension. It is a secondary function of the kidneys. Option 3: Water reabsorption is a primary kidney function. Option 4: The secondary functions of the kidneys include the activation of vitamin D. Option 5: A secondary function of the kidneys is to secrete erythropoietin in response to hypoxia.

The nurse is preparing instructions for a client who is being discharged after undergoing a barium enema. What should be included in the teaching? Select all that apply. 1.No driving is permitted due to sedation used. 2.Take a mild laxative after the procedure. 3.Maintain a low-residue diet for 1 to 3 days. 4.Hold all medications for the rest of the day. 5.Increase oral fluid intake after the procedure. 6.Stools will be light colored for 2 to 3 days after the procedure.

2, 5, and 6 Rationales Option 1: Sedation is not used in a barium enema. Therefore, there are no driving restrictions. Option 2: Barium causes constipation, so the client should take a mild laxative after the procedure to eliminate the barium. Option 3: The client should consume a low-residue diet for several days prior to the procedure, not after. Option 4: The client can resume all medications after the procedure. Option 5: Oral intake should be increased after the procedure due to the constipating side effects of barium. Option 6: The barium will cause the stool to turn a lighter color until it passes. [Page reference: 1017]

A urine specimen is obtained by a client cleaning the exterior meatus, then beginning to void, then collecting the urine sample midstream. Which type of specimen does this describe? 1. Freshly voided specimen 2. Clean-catch specimen 3. Sterile urine specimen 4. 24-hour specimen

2. Rationales Option 1: A freshly voided specimen is collected without using any specific technique. Option 2: A clean-catch urine specimen is collected midstream to avoid contamination from the outer meatus. Option 3: A sterile urine specimen is usually obtained through a straight catheter, with no contact outside the body. Option 4: A 24-hour urine specimen is a collection of all urine voided over 24 hours.

Which is a definition of a therapeutic relationship? 1. The hallmark of nursing practice based on meaningful communication 2. A relationship that focuses on improving the health of the client, whether an individual or community 3. Client-centered care directed at achieving client goals 4. A nurse-client relationship that hinges on evidence-based practice

2. Rationales Option 1: This is Benner's definition of caring. Option 2: This is the correct definition of a therapeutic relationship. Option 3: This is the definition of therapeutic communication that is just as important as the relationship. Option 4: Evidence-based practice is important to therapeutic relationships but is not part of the definition.

A client is admitted to the unit with a left-sided stroke and aphasia. What is the priority nursing diagnosis for this client? 1. Impaired verbal communication 2. At risk for aspiration 3. Anxiety 4. Readiness for enhanced communication

2. Rationales Option 1: This is an important diagnosis, but it is not the priority. Option 2: The client is aphasic and at risk for aspiration, which takes priority. This is an ABC response. Option 3: Anxiety is an important problem, but it is not the priority. Option 4: This is not the priority nursing diagnosis until the client is stabilized.

When caring for a client who is from a different culture, what should the nurse do? 1. Always use touch to demonstrate empathy. 2. Be aware that direct eye contact may be perceived as aggressive or impolite. 3. Present several topics at a time to see how much the client can handle. 4 Tell the client he or she is not able to wear any religious jewelry.

2. Rationales Option 1: Touch may not be accepted by certain cultures. It's always important to assess first. Option 2: In some cultures, eye contact is not therapeutic. Option 3: This would not be a culturally sensitive act. Option 4: Within limits, the nurse should advocate for the client to wear religious jewelry.

Which procedure produces a surgical opening in the abdomen and bypasses the large intestine entirely? 1.Sigmoid colostomy 2.Kock pouch 3.Ileostomy 4.Loop colostomy

3 Rationales Option 1: A sigmoid colostomy is a stoma placed in the distal segment of the colon. Option 2: A Kock pouch is an ileal reserve pouch that collects ileal drainage that is then manually emptied through a stoma. Option 3: An ileostomy brings a portion of the ileum through a surgical opening in the abdomen, bypassing the colon completely. Option 4: A loop colostomy consists of a segment of bowel brought out through the abdominal wall.

A nurse is placing an indwelling catheter in an obese female client and realizes that the catheter is in the vagina rather than the urinary meatus. Which action should the nurse take? 1. Remove the catheter from the vagina and again try to place the catheter. 2. Adjust the client's position or lighting and attempt again with the same catheter. 3. Discard the catheter, adjust the client's position and lighting, and try again with a new catheter. 4. Discard the catheter and ask another nurse to try to place the catheter.

3 Rationales Option 1: Catheter insertion is a sterile procedure, and once the catheter is contaminated, it must be discarded. Option 2: It is appropriate to adjust the client's position, but not to attempt again with the same catheter. Option 3: Once the catheter is contaminated, it cannot be used again for additional placement attempts. Option 4: It is not inappropriate to ask for assistance; rather, the nurse should attempt another placement.

What is the purpose of using a drape when inserting a catheter? 1.Reduces the risk of infection 2.Improves lighting for the procedure 3.Provides privacy for the client 4.Helps regulate temperature

3 Rationales Option 1: Draping provides little protection from infection. Option 2: Draping does not improve lighting during the insertion of a catheter. Option 3: Draping provides comfort and privacy for the client. Option 4: Draping does little to regulate temperature.

The nurse is exploring personal issues with a client and wants to obtain more information. Which question asked by the nurse would obtain the most information? 1. "When did you first notice the problem?" 2. "Do you know why your spouse continues to hurt you?" 3. "Tell me what happened to encourage you to seek counseling." 4."Are there any triggers that you know of that cause the abuse?"

3 Rationales Option 1: Even though this is not a closed question, it does not allow the nurse to obtain a lot of information. Option 2: This question is closed and only provides the nurse with a yes or no answer. Option 3: This is an open-ended question that will hopefully encourage the client to provide information. Option 4: The answer to this question is either a yes or no. This makes it a closed-ended question.

Which is an advantage of intermittent catheterization over indwelling catheters? 1. Convenience to the client 2. Decreased risk of infection 3. Can be removed immediately and client can void normally 4. Convenient for the nurse

3 Rationales Option 1: Intermittent catheterization is not more convenient to the client, as it may be a repeat procedure. Option 2: There is a risk of infection with every catheter insertion. Option 3: An intermittent catheter does not remain in place and the client can resume voiding. Option 4: Intermittent catheterization is not more convenient for the caregiver.

A client reports severe pain in the pubic area and the nurse determines the client has acute urinary retention. The client reports never experiencing this before. Which new medication may be the cause? 1.Lisinopril 2.Ibuprofen 3.Fexofenadine 4.Metoprolol

3 Rationales Option 1: Lisinopril is an ACE inhibitor. It does not cause urinary retention. Option 2: Ibuprofen is a nonsteroidal anti-inflammatory medication used to treat pain. This medication does not lead to urinary retention. Option 3: Fexofenadine is an antihistamine that has a side effect of urinary retention. Option 4: Metoprolol is a beta blocker used to treat hypertension and dysrhythmias. It does not have a side effect of urinary retetion

When inserting an indwelling catheter, which level of asepsis is used? 1. Medical asepsis 2. Disinfection 3. Surgical asepsis 4. Low level asepsis

3 Rationales Option 1: Medical asepsis, or clean technique, is not used during catheter insertion. Option 2: Disinfection refers to removal of pathogens from a nonliving surface. Option 3: Surgical asepsis, or sterile technique, is used for catheter insertion. Option 4: Low level disinfection is only used on inanimate objects.

Which type of communication is a nurse most likely to inadvertently utilize when working with an 84-year-old client who is of the same cultural background as the nurse, and is being seen in the clinic for a follow-up visit for a sprained wrist? 1. Stereotyping 2. Generalizations 3. Elderspeak 4. Failing to probe

3 Rationales Option 1: Nurses should avoid stereotyping clients by age, gender, culture, or ethnicity. In this scenario, as the nurse finds common ground in the client's cultural background, he or she is not as likely to unintentionally use stereotyping communication. Option 2: Nurses should not generalize clients based on educational level or previous health-care experiences. In this scenario, as the client is being seen for a follow-up visit, the nurse is likely to avoid generalizations. Option 3: According to research by Williams, Herman, and Gajewski, elderspeak is a form of patronizing language toward older adults. In this scenario, the nurse is likely to inadvertently utilize elderspeak and should pay special attention to avoid doing so. Option 4: This is a barrier to therapeutic communication, but is not the best answer choice for this particular client.

Which laboratory test should be performed prior to a client undergoing a renal biopsy? 1. Urinalysis 2. Blood glucose 3. Coagulation studies 4. Hepatic function panel

3 Rationales Option 1: The client does not need to have a urinalysis prior to undergoing a renal biopsy. A urinalysis assesses specific gravity as well as the presence of glucose and blood cells. Option 2: The client should not need to have a blood glucose level obtained prior to having a renal biopsy unless the client has diabetes mellitus. Option 3: The nurse should make sure the client has undergone coagulation studies, such as a protime with INR and a partial thromboplastin time, prior to undergoing a renal biopsy. Option 4: Liver function does not need to be assessed prior to undergoing a renal biopsy. Therefore, the nurse would not expect the hepatic function panel to be obtained.

Which laboratory test should be performed prior to a client undergoing a renal biopsy? 1.Urinalysis 2.Blood glucose 3.Coagulation studies 4.Hepatic function panel

3 Rationales Option 1: The client does not need to have a urinalysis prior to undergoing a renal biopsy. A urinalysis assesses specific gravity as well as the presence of glucose and blood cells. Option 2: The client should not need to have a blood glucose level obtained prior to having a renal biopsy unless the client has diabetes mellitus. Option 3: The nurse should make sure the client has undergone coagulation studies, such as a protime with INR and a partial thromboplastin time, prior to undergoing a renal biopsy. Option 4: Liver function does not need to be assessed prior to undergoing a renal biopsy. Therefore, the nurse would not expect the hepatic function panel to be obtained.

The nurse calculates urinary output for a client admitted with dehydration and determines the client's output is 800 mL/day. Which nursing intervention is most appropriate for the nurse to perform first? 1.Notify the health-care provider. 2.Document the finding as normal. 3.Assess the urine color and clarity. 4.Insert an indwelling urinary catheter.

3 Rationales Option 1: The normal daily urine output should be a minimum of 1200 mL. This client is at risk for urinary dysfunction due to low output. However, the nurse needs to obtain more information prior to contacting the health-care provider. Option 2: The nurse should not document the finding as normal, as there is a problem with the urinary output. Option 3: The nurse needs more information prior to notifying the health-care provider. Therefore, the nurse should assess the color and clarity of the urine first. Option 4: The nurse would not insert an indwelling urinary catheter without first obtaining an order from the health-care provider.

How would the nurse assess for costovertebral angle tenderness? 1. Inspect the urinary meatus. 2 Auscultate over the abdominal aorta. 3. Percuss between the 12th rib and spine. 4. Palpate in the pubic area over the bladder.

3 Rationales Option 1: The nurse would inspect the urinary meatus prior to inserting an indwelling urinary catheter. This is not done prior to determining costovertebral angle tenderness. Option 2: The nurse would auscultate over the abdominal aorta to determine the presence of a bruit. This is not assessing for costovertebral angle tenderness. Option 3: The nurse would percuss the area between the 12th rib and spine on both sides to determine the presence of costovertebral angle tenderness. Option 4: The nurse would palpate in the pubic area over the bladder to determine bladder distention; not costovertebral angle tenderness.

. What does the "Q" refer to in the SBARQ communication tool? 1. Qualifications 2. Quantity 3. Questions 4. Quality

3 Rationales Option 1: This is not part of the SBARQ tool. Option 2: This is not part of the SBARQ tool. Option 3: Asking questions is part of the SBARQ tool and an opportunity at the end to review specific concerns. Option 4: This is not part of the SBARQ tool. The tool is designed to provide quality and consistent communication.

A nurse is inserting an indwelling catheter into a client. She begins to inflate the balloon, she feels resistance, and the client complains of discomfort. Which action should the nurse take? 1. Remove the catheter and discard it. 2. Notify the physician and document that the client refused a catheter. 3. Deflate the balloon and advance the catheter about an inch before attempting again. 4. Leave the catheter in place without inflating the balloon.

3 Rationales Option 1: This is not the appropriate action to take in this situation. Option 2: This is not the appropriate action to take in this situation. Option 3: The balloon is likely in the urethra; advancing it will place it in the bladder correctly. Option 4: The catheter will not stay in place without the balloon being inflated.

In the communication process, what does the nurse understand that the channel is? 1. The observer, listener, and interpreter of the message 2. The process of selecting words, tones, and gestures used to transmit the message 3. A method to send the message 4. The process of verbal, nonverbal communication, or both that validate the receiver received message

3 Rationales Option 1: This is the receiver part of the process. Option 2: This is the encoding part of the process. Option 3: The channel involves face-to-face, written information, phone communication, and the Internet to share the message. Option 4: This is the definition of feedback.

The nurse is caring for a 7-year-old client admitted for pneumonia. Which action made by the nurse would facilitate communication with the child? 1.Cuddling with a favorite toy 2.Soothing talk and gentle touch 3.Using words and phrases the child understands 4.Explaining the disease processes and treatments provided.

3 Rationales Option 1: This statement reflects an aggressive way of communicating with others as the person speaking is acting as if he or she is right and there is no other way to perform the task. Option 2: The nurse stating that he or she is okay with the decision made indicates a passive style of communication. Option 3: This nonassertive communication is providing information to the health-care provider in an indirect manner without telling the health-care provider what to do. Option 4: This is an example of assertive communication, as the nurse is stating what he or she believes and cites research to back the statement.

Which phase of the nurse-client relationship allows the client to express thoughts and feelings to the nurse? 1. Preorientation phase 2. Orientation phase 3. Working phase 4. Termination phase

3 Rationales Option 1: The nurse will lay the groundwork during the preorientation phase. No client contact has been made yet. Option 2: The orientation phase is when trust is established and the client and nurse are introduced to each other. Option 3: The client will express thoughts and feelings to the nurse in the working phase. Option 4: The termination phase occurs when goals are met and the nurse-client relationship ends.

Which type of catheter should a client who is receiving a continuous irrigation have? 1.Single-lumen catheter 2.Double-lumen catheter 3.Triple-lumen catheter 4.Quad-lumen catheter

3 (foley catheter) Rationales Option 1: A client receiving continuous irrigation needs more than one lumen in the catheter. Option 2: A client receiving continuous irrigation needs more than a double lumen in the catheter. Option 3: A triple-lumen catheter provides one lumen for injecting the balloon, one lumen for irrigation, and one lumen for the solution and urine to flow out of the bladder. Option 4: A quad-lumen catheter is not needed for continuous bladder irrigation.

Place the anatomical structures in the order in which blood is filtered. 1.Urine from the ureters is stored in the bladder. 2.Urine is carried from the kidneys to the bladder through the ureters. 3.The kidneys contain nephrons, which perform filtration of blood and forms urine. 4.The urinary meatus is the way in which urine leaves the body.

3, 2, 1,4 Correct Feedback Blood is taken into the nephrons, which are in the renal cortex of the kidney. Blood is filtered and urine is formed. Urine is transported from the kidneys to the bladder through the ureters. Urine is then stored in the bladder until it is expelled from the body through the urinary meatus.

What is the effect of physical activity on normal defecation? 1. Increased physical activity can increase constipation. 2. Decreased physical activity can result in diarrhea. 3.Increased physical activity promotes normal defecation patterns. 4.Physical activity has no effect on defecation patterns.

3. Rationales Option 1: Constipation does not occur as a result of increased physical activity. Option 2: Immobility usually leads to slowed peristalsis and constipation. Option 3: Physical activity promotes normal defecation and can relieve constipation. Option 4: Regular physical activity promotes normal defecation patterns. Decreased activity leads to constipation

Which piece of information is most important for the nurse to obtain prior to removing an indwelling urinary catheter? 1. Date of insertion 2. Type of catheter material 3. Amount of saline in balloon 4. Allergy to betadine or shellfish

3. Rationales Option 1: The date of insertion is not the most important aspect to know prior to the removal of an indwelling urinary catheter. The nurse may need to know this prior to changing the catheter. Option 2: The nurse would need to pay attention to the type of material used prior to insertion, especially if the client has a latex allergy. However, this is not needed prior to removal. Option 3: The nurse would need to know the amount of saline inserted into the balloon prior to removing the catheter. This allows the nurse to use the correct syringe size and to ensure the nurse removes all of the saline before pulling the catheter out. Option 4: The nurse would need to know allergies to betadine and shellfish prior to inserting the catheter as betadine is used in the prep. This is not necessary to know prior to removal.

The nurse is preparing to remove an indwelling urinary catheter from a client who underwent a prostatectomy a week ago. Which size syringe would be most appropriate for the nurse to use to deflate the retention balloon? 1.3 mL 2.5 mL 3.10 mL 4.30 mL

4 Rationales Option 1: A 3-mL syringe is too small for removing the water from the retention balloon for an adult. It is the correct size for a child. Option 2: A 5-mL syringe would be used to remove an indwelling urinary catheter from an adult client who did not have a urological procedure performed. Option 3: Sometimes a 10-mL syringe is used to inflate a retention balloon in an adult client who uses an indwelling urinary catheter on a long-term basis. However, this is a catheter used after a urological procedure. Option 4: A urologist would insert an indwelling urinary catheter with a 30-mL retention balloon in a client who underwent prostate surgery. This would prevent the catheter from being pulled out.

The nurse is caring for a client with acute kidney injury and reviews the medical record for new orders. Which order given by the health-care provider should the nurse question? 1. Cystoscopy 2. Cystometry 3. Renal biopsy 4. Intravenous pyelogram

4 Rationales Option 1: A cystoscopy is not contraindicated for a client with acute kidney injury. This procedure could be used to remove stones that may be causing the acute kidney injury. Option 2: Cystometry is used to measure the amount of urine in the bladder as well as the amount of pressure in the bladder. This test would be allowed for this client. Option 3: A renal biopsy is a procedure that could be used to determine the cause of acute kidney injury. It is not contraindicated. Option 4: An intravenous pyelogram is contraindicated in a client with acute kidney injury, as the intravenous dye is nephrotoxic and can worsen the kidney injury.

The nurse working at a community center wants to begin a group for clients who want to lose weight. Which type of group would the nurse develop? 1.Task group 2.Therapy group 3.Ongoing group 4.Self-help group

4 Rationales Option 1: A task group is a subcommittee of people working on a project, such as a group of nurses developing a new protocol. Option 2: A therapy group is beneficial for clients to discuss problems encountered with being overweight; however, this would not be a group to motivate and provide weight loss strategies. Option 3: An ongoing group is a group that continues to meet on a routine basis and is not related to tasks. An example is a hospital's ethics group. Option 4: A self-help group benefits the group of clients who wish to work together to lose weight.

During digital removal of stool, which is the most serious complication the client is at risk of developing? 1. Bleeding 2. Decreased blood pressure 3. Hypertension 4. Decreased heart rate

4 Rationales Option 1: Although there is a remote possibility of bleeding occurring with digital removal of stool, this is not the priority consideration. Option 2: The client may be at slight risk for hypotension, but this is not the priority consideration. Option 3: Hypertension may occur as a result of discomfort and stress, but this is not the most serious complication. Option 4: Digital disimpaction can stimulate the vagus nerve, which causes a reflex slowing of the heart rate.

Which type of enema may be ordered to help a client pass flatus and relieve abdominal distention? 1.Oil-retention enema 2.Medicated enema 3.Nutritive enema 4.Return-flow enema

4 Rationales Option 1: An oil-retention enema is administered to soften stool and lubricate the rectum. Option 2: A medicated enema is administered to instill medication into the rectum. It is most often used for infection or parasite infestation. Option 3: A nutritive enema delivers nutrients into the body for the severely dehydrated or frail. Option 4: A return-flow enema, or Harris flush, is given to relieve discomfort associated with distention and flatus.

What is the term for the amount of blood that is filtered in a minute? 1. Creatinine 2. Ammonia 3. Blood urea nitrogen 4. Glomerular filtration rate

4 Rationales Option 1: Creatinine is a nitrogenous waste product that is excreted by the kidneys. Option 2: Ammonia is a waste product of protein metabolism. It is not the term for the amount of blood filtered in a minute. Option 3: Blood urea nitrogen is a nitrogenous waste product. It is not the term for the amount of blood filtered in a minute. Option 4: The glomerular filtration rate measures the amount of blood that is filtered through the glomerulus in a minute.

A nurse is caring for a client with type 2 diabetes mellitus who is scheduled to undergo a computed tomography (CT) scan with IV contrast of the abdomen due to suspected intestinal malignancy. Which medication should the nurse hold prior to the procedure and for 48 hours after the procedure? 1.Insulin 2.Diazepam 3.Bisacodyl 4.Metformin

4 Rationales Option 1: Insulin is a medication that would be required for a client with diabetes mellitus. It does not interfere with the test. Option 2: Diazepam would be administered to sedate a client if needed during the procedure. It is safe to give with IV dye. Option 3: The client would take bisacodyl prior to a colonoscopy to clear the bowel. This is not contraindicated for the procedure. Option 4: Metformin when taken in combination with IV dye can cause renal failure. Therefore, the nurse should withhold this medication.

A client presents to the emergency room with vomiting and diarrhea. The client is dehydrated. Which hormone does the nurse expect to be secreted by the posterior pituitary gland to reduce water loss? 1. Renin 2. Aldosterone 3. Erythropoietin 4. Antidiuretic hormone (ADH)

4 Rationales Option 1: Renin is secreted by the kidneys to increase blood pressure. Option 2: While aldosterone does promote water retention, it is produced by the adrenal cortex, not the posterior pituitary gland. Option 3: Erythropoietin is a hormone produced by the kidneys to increase red blood cell production. Option 4: ADH is a hormone manufactured by the posterior pituitary gland in response to water loss.

The nurse is caring for a client who is being discharged after sustaining a myocardial infarction. What is most important for the nurse to instruct the client? 1.Consume a bland diet. 2.Use a salt substitute on foods. 3.Avoid consuming grapefruits and its juice. 4.Take stool softeners to prevent straining.

4 Rationales Option 1: The client with gastrointestinal reflux disease may require a bland diet; however, it is not applicable for this client. Option 2: While salt substitute use is inappropriate for a client on a diuretic, there is no indication the client is receiving diuretics. Option 3: Grapefruit and its juice is contraindicated for clients taking statins. There is no documentation this client is receiving statin therapy; therefore, the nurse would not include this in the instructions. Option 4: A client who has heart disease should never bear down to strain with bowel movements (Valsalva maneuver), as this can cause cardiac arrhythmias or cardiac arrest.

How long should the nurse auscultate each quadrant prior to documenting the absence of bowel sounds? 1. 30 seconds 2. 1 minute 3. 2 minutes 4. 3 minutes

4 Rationales Option 1: The nurse should listen to bowel sounds for longer than 30 seconds to determine the absence of bowel sounds. Option 2: One minute is not a sufficient amount of time for the nurse to auscultate each quadrant before documenting the absence of bowel sounds. Option 3: The nurse would listen for more than 2 minutes prior to documenting that the client has absent bowel sounds. Option 4: The nurse should auscultate each quadrant for a minimum of 3 minutes prior to documenting absent bowel sounds.

A client asks the nurse to take a laxative, as he or she has not had a bowel movement today. What is the first information the nurse should obtain prior to administering the laxative? 1.The amount of fiber in daily diet 2.The last dose of laxative received 3.If the client has had any flatus 4.The client's normal bowel elimination pattern

4 Rationales Option 1: The nurse would assess causative factors in a client with chronic constipation; however, this is not information that the nurse would obtain first. Option 2: The nurse would obtain information regarding when the client took the last dose of the laxative, but this would not be the first piece of information obtained by the nurse. Option 3: The nurse would obtain other information first before asking about the presence of flatus. Option 4: The nurse should ask the client what his or her normal bowel pattern is prior to giving a laxative. If the client has a bowel movement every other day, then the client may not need the laxative.

The parents of a newborn voice concern regarding looser stools that the newborn is experiencing after each breastfeeding. What would be the nurse's best response? 1. "Let's obtain a stool sample and we can run tests." 2. "Have you recently switched formulas for the baby?" 3. "What are the color of the stools the newborn is passing?" 4. "This is normal because newborns have looser stools due to immature intestines."

4 Rationales Option 1: The nurse would not automatically obtain a stool sample without obtaining more information. Option 2: The parents report the newborn is breastfeeding. Therefore, the nurse would not ask the parents this information. Option 3: The color of the stools would change based on breastfeeding vs. bottle feeding. This would not be the best option for the nurse to ask. Option 4: A newborn has an immature large intestine. This changes over time as normal intestinal flora develops.

he nurse has an order to obtain a urine specimen for a culture and sensitivity test from a client with an indwelling urinary catheter. Which procedure is accurate for obtaining the specimen? 1. Obtaining the specimen from the drainage bag 2. Disconnecting the tubing and obtaining the specimen 3. Inserting a new indwelling urinary catheter to obtain a sterile urine specimen 4. Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically

4 Rationales Option 1: The nurse would not obtain the sample from the drainage bag, as it may be several hours old. Option 2: The nurse should not disconnect the seal between the drainage bag and the catheter. This opens the tubing and places the client at risk for infection. Option 3: The nurse would not need to insert a new indwelling urinary catheter because this is not needed. Option 4: The nurse would clamp the tubing and withdraw a fresh specimen from the tubing aseptically. This ensures the specimen is sterile and not contaminated

18. Which is an appropriate elimination-related nursing diagnosis for a client who is on bedrest following surgery, and is also taking opioid pain medications? 1.Risk for bowel incontinence 2.Risk for infection related to diarrhea 3.Altered tissue integrity related to incontinence 4.Risk for constipation related to immobility

4 Rationales Option 1: There is not an identified risk for incontinence. Option 2: The client has not been identified as having a risk of infection or diarrhea. Option 3: There is no information to support this nursing diagnosis. Option 4: The client has just had surgery, is on bedrest, and is taking opioid medications, all of which increase the risk of constipation.

What is the purpose of the SBARQ model? 1.To provide communication during client rounding 2.To provide shift-to-shift reports between nurses 3.To document care in the client's chart 4.To provide consistent communication when there is a change in a client's condition

4 Rationales Option 1: This tool is not used during physician and nurse rounds. Option 2: The purpose of this tool is not to document shift-to-shift reports. Option 3: The SBARQ model is not a standardized documentation tool in the medical record. Option 4: The purpose of the SBARQ model is to standardize communication between nurses and providers when a client's health status changes.

A client has a tendency to develop frequent constipation. Which dietary consideration should the nurse recommend? 1. The client should increase iron intake. 2. The client should decrease fiber intake. 3. The client should increase intake of fats. 4. The client should increase fiber intake.

4 Rationales Option 1: Iron can contribute to constipation. Option 2: Fiber promotes peristalsis and defecation, so fiber should not be decreased. Option 3: Fats do not help alleviate constipation. Option 4: Fiber promotes peristalsis and defecation. An increase in dietary fiber can alleviate constipation.

There are four essential phases of a therapeutic relationship. Place these statements in order from first phase to last phase. 1.Termination phase 2. Orientation phase 3. Working phase 4. Pre-interaction phase

4, 2, 3, 1

Place the nurse's notes in order according to the SBAR documentation system. 1.The nurse will continue to assess the wound every 4 hours. 2.The client underwent a colon resection due to colon cancer. 3.The abdominal wound staples are intact without drainage. 4.The client is lying in bed reading the newspaper.

4, 2, 3, 1 According to the SBAR system (Situation, Background, Assessment, and Recommendation), the situation is the client lying in bed reading the newspaper. The nurse received a report that the client had a colon resection due to colon cancer, which is the background. The wound assessment is the assessment portion of SBAR, and the recommendation is to continue to assess the wound every 4 hours.

With which type of bowel diversion is the client most likely to have control over bowel elimination and not need to wear an appliance? 1. Ileostomy 2. Ascending colon colostomy 3. Transverse colon colostomy 4. Sigmoid colostomy

4. Rationales Option 1: An ileostomy yields liquid and almost continuous stool. An appliance must be worn. Option 2: A colostomy of the ascending colon yields mostly liquid stool that must be collected with an appliance. Option 3: A transverse colon colostomy has a more formed stool than ascending, but is not formed enough to go without an appliance. Option 4: A sigmoid colostomy is closest to the rectum. Stool is most likely to be formed and can often be controlled without the use of an appliance.

Question 10. With which person is it most beneficial for the nurse to use empathy in communicating? 1. A client who is angry and inappropriate with the nursing staff 2.A school-aged child who does not understand what the treatment is 3.A client who wishes to have 2 hours of uninterrupted sleep before dinner 4.A spouse of a client who just passed away

4. Rationales Option 1: The nurse uses confrontation with this client regarding the behaviors, and then sets limits with the client. Option 2: The nurse uses concrete explanations for a school-aged child to explain the treatment prescribed. Option 3: If at all possible, the nurse uses respect to allow the client 2 hours of sleep without interruptions prior to dinner. Option 4: The nurse uses empathy to talk with the spouse of the client who just passed away. This allows the nurse to emotionally place himself or herself in the spouse's place.

Which statement is an example of elderspeak? 1. "What time would you like your dinner?" 2. "Do you know when your daughter is coming to visit?" 3. "I will bring your medications to you in a few minutes." 4. "Sweetie, when do we want to take our bath?"

4. Rationales Option 1: This is not an example of elderspeak. It asks the client a straightforward question and does not speak to the client in a demeaning manner. Option 2: This is asking the client a question without being condescending. This is not an example of elderspeak. Option 3: The nurse is informing the client when medications will be given. This is not an example of elderspeak. Option 4: The nurse is using elderspeak when referring to the client by a name such as "Sweetie" or "Dearie." This may irritate older adults and is disrespectful.