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WorksheetsNSG 3100 Exam 3 Review
Total questions: 131
Worksheet time: 3hrs 42mins
The nurse is caring for a patient who has diabetes. The patient reports compliance with the medical regime. Which test result indicates to the nurse that the patient has not been compliant with the treatment plan?
Hemoglobin A1c 16%
Random blood sugar (RBS) 112 mg/dL
Lactate dehydrogenase (LDH) 55 units/L
Erythrocyte sedimentation rate (ESR) 14 mm/hr
The nurse is caring for an elderly patient with dementia. Which laboratory finding indicates to the nurse that that patient is often forgetting to eat meals?
Serum bilirubin 0.4 mg/dL
PLT (platelet count) 425,000/mm3
Serum cholesterol 175 mg/dL
Albumin 2.1 g/dL
The nurse is caring for a patient who has a deep leg wound that is badly infected. Which laboratory test results will the nurse expect to find in the patient’s chart?
Elevated C-reactive protein (CRP) 6.5 mg/dL
Decreased serum creatinine 0.8 mg/dL
Elevated serum bilirubin 0.5 mg/dL
Prothrombin time (PT) 11.5 seconds
The nurse is caring for a patient who has a bleeding gastric ulcer. How will the nurse expect the patient’s stool to appear?
Soft and formed with bright red streaks
Watery with particles of undigested food
Sticky and black
Hard lumps that are difficult to pass
The nurse is caring for a patient who is to have a noncontrast MRI scan performed. Which assessment finding leads the nurse to report that the patient may not be able to have the test?
The patient has an implanted insulin pump.
The patient is breastfeeding her newborn infant.
The patient is severely allergic to iodine and latex.
The patient has profound hearing loss.
The nurse is caring for a patient who has had severe acid reflux. Which test will allow the physician to directly check for damage to the esophagus?
Esophagogastroduodenoscopy (EGD)
MRI scan with contrast
Abdominal ultrasound
Positron emission tomography (PET) scan
The nurse is caring for a woman who has a cyst in her breast that was found at her recent mammogram. The physician wants to make sure that the cyst is not malignant. Which test will be used to determine this?
Needle aspiration with biopsy
Paracentesis
Thoracentesis
Endoscopy
The nurse is caring for a patient who is scheduled for a needle aspiration and biopsy to rule out cancer. Which nursing diagnosis is appropriate and important for this patient?
Anxiety related to potential for cancer diagnosis depending on biopsy results.
Impaired health maintenance related to delayed insurance coverage for procedure.
Powerlessness related to lengthy wait for diagnosis.
Impaired coping process related to patient stated she is a little nervous about the test results.
The nurse is caring for a patient who will be undergoing flexible sigmoidoscopy testing to screen for colon cancer. What goal will the nurse include in the patient’s plan of care?
Patient will verbalize understanding of preprocedure preparation to be completed at home the day before the test.
Patient will feel comfortable about the upcoming test and have trust in the health care providers.
Patient will learn common side effects of the medications used to prepare the GI tract for endoscopy testing.
Patient will realize how important regular sigmoidoscopy testing is in the prevention of colon cancer.
The nurse is caring for a patient who will be receiving iodine-based contrast medium for a CT scan. Which allergy should be reported to the technician and radiologist before the test is performed?
Gluten and lactose
Strawberries and blueberries
Peanuts and cashews
Shrimp and scallops
The nurse is caring for a patient who has just undergone bronchoscopy. The patient requests a drink of water. What is the nurse’s best action?
Provide ice chips.
Check the patient for a gag reflex.
Provide a small cup of ice water with a straw.
Keep the patient NPO
The nurse is caring for a patient who is sedated following a colonoscopy. Which is the priority action of the nurse?
Provide a quiet, dark environment so that the patient can rest comfortably.
Monitor the patient’s pulse oximetry and respirations closely.
Inform the patient that the procedure has been completed.
Assess the patient’s bowel sounds and passage of flatus.
The nurse is caring for a patient who recently had a liver biopsy. To whom must the nurse give the results?
The patient
The patient’s health care provider
The patient’s insurance provider
The patient’s spouse
The nurse is caring for a patient who is to collect a 24-hour urine specimen. Which statement by the patient indicates that additional teaching is required?
“I will keep the urine container on ice to keep it chilled until I bring it to the lab.”
“I will start the test over if I forget and urinate into the toilet during the testing time.”
“I will start the test tomorrow after I urinate first thing in the morning.”
“I will drink extra fluids so that the lab will have a large specimen to test.”
The nurse is caring for a patient whose immune system is destroying red blood cells at a very rapid rate. Which test result will the nurse expect to see in the patient’s chart as a result?
Bilirubin level 4 mg/dL
Platelet count 450,000/mm3
Potassium 3.2 mEq/L
Partial thromboplastin time 45 seconds
The nurse is caring for a patient with a urinary tract infection. Which test will indicate which antibiotics will be effective to treat the infection?
Complete blood count (CBC)
Culture and sensitivity (C&S)
Renal scan and angiography
Radioreceptor assay for HCG
The nurse is caring for a patient who has just undergone paracentesis. For which complication will the nurse carefully monitor?
Collapse of the lung with shortness of breath.
Fecal impaction from retained barium in the colon.
Cerebrospinal fluid leak resulting in severe headache.
Perforation of the bowel resulting in abdominal infection.
The nurse is caring for a patient with diabetes who will be doing fingerstick blood glucose testing at home. What is the best way for the nurse to ensure that the patient can perform the procedure correctly?
Quiz the patient on the steps of the procedure.
Have the patient perform the procedure in front of the nurse.
Ask the patient if he has any questions about the test.
Use terminology that the patient can easily understand.
The nurse is caring for a patient with a neurological condition that causes constant severe thirst, drinking fluids continuously, and voiding 3 to 4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this patient’s urinary output?
Anuria
Oliguria
Polyuria
Enuresis
The nurse is caring for a patient who is experiencing stress incontinence. The nurse identifies which goal to be the most important for this patient?
The patient will carefully complete a voiding diary for the duration of 2 weeks.
The patient will not experience involuntary urination during coughing or sneezing.
The patient will be able to recognize and effectively manage perineal dermatitis.
The patient will demonstrate how to appropriately use urinary incontinence products.
The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse?
Encourage oral fluid intake and administer a diuretic.
Obtain a urine sample to test for culture and sensitivity.
Calculate the patient’s daily intake and output.
Obtain an order to straight-catheterize the patient.
The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine in the toilet. Which is the priority assessment to be performed by the nurse?
Bladder scan to determine the amount of urine in the bladder.
Auscultation to assess circulation through the right and left renal arteries.
Bimanual palpation to assess for possible enlargement of the kidneys.
Calculate the patient’s intake and output to check for fluid volume deficit.
The nurse is caring for a seriously ill patient whose laboratory results show a serum creatinine level of 3.5 mg/dL and a serum BUN of 35 mg/dL. Which conclusion can the nurse draw from these test results?
The patient is severely dehydrated.
The patient’s kidneys have been damaged.
The patient has a urinary tract infection.
The patient has developed a renal calculus.
The nurse is caring for a patient who will undergo ultrasound testing of the bladder and kidneys the next morning. Which instruction will the nurse provide to the patient about the test?
“A small IV will be inserted into your arm to inject the contrast dye.”
“You will need to drink lots of water but not use the toilet.”
“You should not have anything to eat or drink after midnight.”
“You will receive a cleansing enema before you have the test.”
The nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder. Which action will the nurse take to facilitate this procedure?
Obtain a Coudé catheter for insertion.
Attach a leg bag to the catheter prior to insertion.
Trim the pubic hair before cleaning the perineal area.
Wait until the bladder is full to perform catheterization.
The nurse is caring for a patient who has just had an intravenous pyelography (IVP) completed. Which assessment is the nurse’s highest priority after the patient returns from the test?
Calculate the patient’s intake and output.
Monitor for discoloration of the patient’s urine.
Assess for possible iodine or shellfish allergies.
Inquire if the patient has burning or pain with urination.
The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient’s bladder. What is the priority nursing diagnosis for this patient?
Anxiety r/t continual urge to urinate
Reflex incontinence of urine r/t over-distention of the bladder
Impaired urination r/t obstruction of urinary bladder outlet
Impaired self-toileting r/t inability to pass urine into the toilet
The nurse is caring for a patient who had prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake. The patient’s urine from the indwelling catheter is cherry red with occasional small clots. What is the appropriate action of the nurse?
Remove the urinary catheter and replace it with a new one.
Gently irrigate the catheter using room-temperature sterile irrigation solution.
Send a sample of the patient’s urine to the laboratory for analysis.
Call the provider and obtain an order for kidney and bladder ultrasound.
The nurse is caring for a patient with the nursing diagnosis of urge incontinence of urine related to urinary tract infection. Which statement is appropriate for the “as evidenced by” portion of the patient’s diagnosis?
Sudden leakage of urine when patient is unable to get to the toilet in time
Continuous urine flow from the bladder regardless of attempts to use the toilet
Leakage of urine from the bladder when the patient coughs, sneezes, or laughs
Leakage of urine because the patient is unable to indicate need to use the toilet
The preceptor is watching a nursing student care for a male patient who requires a condom catheter. Which action by the nursing student indicates that the procedure is performed correctly?
Sterile gloves are donned before touching the catheter.
Adhesive tape is applied securely around the base of the penis.
Water-soluble lubricant is applied to the end of the catheter.
The foreskin is returned to its natural position before the catheter is applied.
The nurse is caring for a patient who is to undergo computed tomography (CT) of the kidneys and ureters. Which assessment finding by the nurse must be reported to the provider and radiologist before the patient has the procedure?
The patient is allergic to bananas and latex.
The patient thinks that she might be pregnant.
The patient has a family history of bladder cancer.
The patient currently has a urinary tract infection.
The nurse is caring for an elderly patient whose dementia has become worse over the last 24 hours. The nurse suspects that the patient may have developed a urinary tract infection and obtains a urine sample. Which assessment findings prompt the nurse to contact the provider to obtain an order for urine culture and sensitivity testing? (Select all that apply.)
Urinary dipstick testing is positive for nitrates.
The urine appears cloudy with a foul odor.
The urine smells faintly like sweet fruit
The patient is urinating more frequently than usual.
The patient is normally continent but has been incontinent twice.
The nurse is caring for a patient who is to complete a 24-hour urine collection to measure creatinine clearance. Which tasks related to this test may be delegated to the nursing assistant? (Select all that apply.)
Teaching the patient about sterile specimen collection
Keeping the urine collection container cool on ice
Dumping the urine from the patient’s first void
Reminding the patient not to put toilet paper in the urine
Transporting the specimen to the laboratory for testing
The nurse is caring for a patient who periodically has small streaks of fresh red blood in the stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be the most likely cause of this patient’s bleeding?
Hemorrhoids
Bleeding gastric ulcer
Colon polyps
Perforated colon
The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil). Which assessment finding by the nurse indicates a need to contact the prescriber and question the order?
The patient has skin breakdown from loose stools.
The patient is constipated with last BM 3 days ago.
The patient is on a low-fiber, gluten-free diet.
The patient has painful bleeding hemorrhoids.
The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority?
Provide oral care after each episode of emesis.
Apply a skin barrier to the patient’s perineal area.
Check the patient for a fecal impaction.
Administer antiemetic medication with a sip of water.
The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon?
The patient has bowel sounds × 4 quadrants and is passing gas.
The patient has no nausea, and abdominal pain is minimal.
The patient feels hungry for chicken soup and hot tea.
The patient’s nasogastric tube was discontinued the previous day.
The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function?
Raisin bran with skim milk, fresh fruit, and wheat toast.
Pancakes with maple syrup, bacon, and coffee with cream.
Omelet with cheddar cheese, green pepper, and onions.
Bagel with cream cheese, and strawberry nonfat yogurt.
The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient?
Obtain an order to administer a soap suds cleansing enema.
Teach the patient how to use the Valsalva maneuver.
Discontinue medications that can cause constipation.
Assess the patient’s usual pattern of bowel movements.
The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam?
“The back of your throat will be sprayed with numbing medicine.”
“You will need to have a clear liquid diet and take a laxative tonight.”
“You will be given a milky liquid to drink shortly before the test starts.”
“You should not take your dose of warfarin (Coumadin) tonight.”
The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing?
Keep the patient on a clear liquid diet for 72 hours.
Put the sample container on ice and send to the lab immediately after collection.
Inform the patient that several stool samples will be needed.
Use a sterile container when collecting the stool samples.
The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding by the nurse indicates a need to contact the prescriber and question the order?
The patient is recovering from a traumatic brain injury.
The patient has not had a bowel movement for 3 days.
The patient is to have a lower GI series the following morning.
The patient had an upper GI series performed the previous day.
The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient’s abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse?
Keep the patient NPO and document the findings in the chart.
Administer a laxative suppository to stimulate peristalsis.
Insert a Salem sump nasogastric tube to low continuous suction.
Notify the surgeon and prepare the patient to return to surgery.
The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement?
Glass of warmed prune juice
Loperamide (Imodium)
Oral fiber supplement
An oil retention enema
The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient’s new symptoms?
Clostridium difficile infection
Paralytic ileus
Fecal impaction
Salmonella food poisoning
The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse?
Assist the patient to ambulate in the hall.
Insert a rectal tube to remove retained flatus.
Administer an enema to stimulate peristalsis.
Encourage oral intake of fluids and high-fiber foods.
The nurse is caring for a patient with a history of dementia who is incontinent of stool because of the inability to communicate the need to defecate. What is the priority action of the nurse?
Administer a daily laxative and take the patient to the toilet afterward.
Digitally remove stool from the patient’s rectum every other day.
Insert a rectal tube to facilitate drainage of soft or liquid stool.
Begin a prompted toileting program to facilitate bowel continence.
The nurse is caring for a patient who is recovering from diarrhea. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed?
Applesauce
Orange popsicle
White toast
Coffee with cream
The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions can the nurse delegate to the nursing assistant? (Select all that apply.)
Gently cleaning the stoma with warm water and a washcloth
Obtaining needed supplies from the clean utility room
Teaching the patient how to care for the ostomy after discharge
Application of skin protectant to the area surrounding the stoma
Determining which type of ostomy appliance to use
The nurse is caring for a patient who will be having a colonoscopy the following morning. Which items must be removed from the patient’s dinner tray since they are not allowed prior to the test? (Select all that apply.)
Cherry-flavored gelatin
Cream of chicken soup
Coffee with cream and sugar
Lemon-flavored Italian ice
Can of ginger ale
The nurse identifies which medication that has the highest potential for abuse?
Methylphenidate (Ritalin)—schedule II
Alprazolam (Xanax)—schedule IV
Acetaminophen & codeine (Tylenol #3)—schedule III
Diphenoxylate & atropine (Lomotil)—schedule V
The nurse is caring for a patient who will self-administer medication injections at home after discharge. How can the nurse best determine that the patient understands the technique and can administer the injections correctly?
Provide written instructions about how to administer the injections.
Watch the patient self-administer an injection.
Call the patient the next day to ask if there is any difficulty with administering the injections.
Ask the patient to express understanding as to how to administer the injections.
The nurse is caring for a patient who is in agonizing pain. All the following options are listed on the patient’s medication order sheet to relieve pain. The nurse knows which option that will provide the most rapid pain relief for the patient?
Morphine (MSContin) 10 mg PO
Hydromorphone (Dilaudid) 1 mg IV push
Meperidine (Demerol) 75 mg IM
Fentanyl (Duragesic) 50 mcg transdermal patch
The nurse administers a medication to a patient. Shortly afterward, the patient develops an itchy rash over the entire body and reports feeling very unwell. What is the priority action of the nurse?
Leave the patient to notify the provider and the pharmacist.
Determine if the patient is having any difficulty breathing.
Document the reaction in the patient’s chart.
Obtain an order for hydrocortisone cream to relieve the itching.
The nurse identifies which medication order to be administered PRN?
Zolpidem (Ambien) 10 mg PO tonight if the patient cannot sleep
Prednisone 10 mg PO today, then taper down 1 mg each day for the next 10 days
Humulin R 10 units subcutaneously before each meal and at bedtime
Kefzol (Ancef) 1 g IVPB 30 minutes prior to surgery
After administering an antibiotic to the patient, the nurse notes the patient complaining of feeling ill is scratching and has hives. The patient soon starts having difficulty breathing and is hypotensive. What is the nurse’s assessment of the situation?
The patient is having a mild allergic reaction and an antihistamine will make the patient feel better.
The patient is having an anaphylactic reaction and epinephrine should be administered right away.
The patient’s infection is worsening and progressing to septic shock so blood cultures should be drawn.
The patient has developed toxic shock syndrome and the antibiotic orders must be changed right away.
The nurse makes a medication error. Which action will the nurse take first?
Prepare an incident report.
Explain to the patient that a medication error has occurred.
Assess the patient for any adverse reactions.
Document the medication given, the response, and corrective actions taken.
The nurse prepares to administer the following medication to the patient. Which instruction will the nurse be sure to give before the patient takes the medication?
“Be sure to swallow the pill whole.”
“Crush the medication and place the powder in applesauce.”
“Place the pill under your tongue.”
“Let the pill slowly dissolve in your mouth.”
The nurse begins a shift on a busy medical-surgical unit and will be caring for multiple patients. Which patient does the nurse assess first?
A patient who would like some acetaminophen (Tylenol) for a mild headache
A patient who has a question about her daily medications
A patient who needs discharge teaching about an antibiotic
A patient who just received nitroglycerin for chest pain
The nurse carefully reviews the patient’s medication list. Which observation about the list indicates the highest risk for serious drug-drug interactions?
The patient has been taking the same medications for a long time.
The patient is taking a large number of medications.
Most of the drugs on the list are prescribed at high doses.
The patient takes oral, injected, and inhaled medications.
The nurse is caring for a patient who is taking many prescription medications for various health problems. Which direction from the nurse will help the patient avoid dangerous drug interactions?
Only take over-the-counter medications.
Have all of the prescriptions filled at the same pharmacy.
Avoid taking generic preparations of prescribed medications.
Only take the medications that the patient feels are necessary.
During discharge teaching, the nurse is to give the patient a signed, dated, and timed prescription from the physician for medications to be taken at home. Which prescription drug order needs to be corrected before it is given to the patient?
Warfarin (Coumadin) 5 mg PO daily before dinner
Methotrexate (Trexall) 8 tablets PO once weekly on Saturdays
Levothyroxine (Synthroid) 137 mcg PO daily before breakfast
Zolpidem (Ambien) 5 mg PO at bedtime as needed for sleep
The nurse administers a medication to the patient. Which symptoms indicate to the nurse that the patient is having an allergic reaction rather than a side effect?
Hair loss and sweaty skin
Nausea and constipation
Heartburn and nasty taste in the mouth
Itchy rash and difficulty breathing
The nurse is caring for a patient who is receiving vancomycin (Vancocin) to treat a severe infection. The next dose is due to be administered at 10:00 a.m. What time will the nurse draw the vancomycin serum trough level?
7:30 a.m.
9:30 a.m.
11:30 a.m.
1:30 p.m.
When administering phenytoin (Dilantin) through the patient’s IV line, the nurse carefully flushes the IV with normal saline before and afterward to avoid crystal formation of the medication that occurs when it mixes with dextrose in water (D5W) solution. Which type of drug interaction is the nurse being careful to avoid?
Antagonism
Potentiation
Synergism
Incompatibility
The nurse is noting an order for a medication to be given TID. Which times will the nurse plan to administer the medication to the patient?
9 a.m., 1 p.m., 5 p.m., and 10 p.m.
9 a.m. and 9 p.m.
9 a.m., 1 p.m., and 5 p.m.
Nightly before the patient goes to sleep
The nurse is caring for a patient who was just made NPO. The nurse is to administer carvedilol (Coreg) 25 mg PO to the patient for control of high blood pressure. What is the best action of the nurse?
Crush the medication and administer it to the patient mixed with applesauce.
Administer the medication to the patient with a small sip of water.
Contact the patient’s provider to clarify the order.
Administer the equivalent medication dose through the patient’s IV.
The nurse is to administer 1 mL of prochlorperazine (Compazine) 10 mg IM to an adult patient. Which syringe will the nurse select to administer the medication?
1 mL tuberculin syringe with 27 gauge, 1/2 inch needle
3 mL syringe with 23 gauge, 1 1/2 inch needle
1 mL syringe with 27 gauge, 5/8 inch needle
3 mL syringe with 18 gauge, 1 inch needle
The nurse is caring for a patient who takes 6 tablets of methotrexate once every week on Fridays. How many mg of methotrexate does the patient take per dose?
10 mg
15 mg
20 mg
25 mg
The nurse is to administer 45 mg of phenobarbital to the patient. How many tablets will the patient receive?
1 tablet
2 tablets
3 tablets
4 tablets
The nurse caring for a severely dehydrated patient who has a Foley catheter in place assesses the patient to confirm adequate urine perfusion by the urine output of:
15 mL.
30 mL.
45 mL.
60 mL.
To help reduce a patient's risk of recurrent cystitis, the nurse teaches the patient to:
eat citrus fruits to alkalinize the urine.
always wipe the perineal area from back to front.
take long, warm bubble baths.
wear cotton underwear and avoid nylon or constrictive clothing.
The nurse is aware that in the older adult, a urinary infection may cause the patient to:
run an exceptionally high temperature.
have foul urine and diarrhea.
become disoriented and confused.
become irritable.
To prevent changes in the chemical characteristics of urine, a nurse sends a sample of fresh urine to the laboratory for urinalysis within at least:
1 to 2 minutes.
3 to 5 minutes.
5 to 10 minutes.
20 to 30 minutes.
A patient has been ordered to have a 24-hour urine collection as part of a diagnostic workup. The action taken to perform this procedure correctly is to:
continue the collection if the patient accidentally voids directly into the toilet.
obtain a container and put it in a warm water bath in the bathroom.
have the patient void at the beginning of the collection and throw it away.
have the patient void for the last time a few hours before the collection ends.
A nurse would modify the urine collection technique when a urine sample is needed from an infant by:
placing the infant on a bedpan after removing the diaper.
removing the diaper after the infant voids and send the diaper to the laboratory.
attaching a bag with adhesive backing to the skin surrounding the genitals.
applying a very small condom catheter.
The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing intervention in the care of such a patient would be to:
place a sieve over the commode.
obtain an order for indwelling urinary catheter.
place a graduated cylinder near the commode.
attach a urinary leg bag.
When the patient who has an order to be out of bed complains of feeling too weak to walk to the bathroom, the nurse assists the patient with urination elimination by:
acquiring a walker so that the patient can go to the bathroom.
using a fracture bedpan and keep the patient flat.
obtaining a raised toilet seat.
placing a commode at the bedside.
A nurse is observing a nursing assistant offering a bedpan to a patient. The nurse will intervene if the nursing assistant:
closes the bedside curtain.
dons clean gloves.
keeps the head of the bed flat after placing the bedpan.
asks the patient to bend his knees and press down with his feet.
The nurse can assist a patient who needs to void but cannot begin the urinary stream by:
running water in a nearby sink.
pouring cool water over the perineum.
inserting an indwelling catheter.
distracting the patient with conversation.
An adult male patient who cannot void has an order to have a urinary catheter inserted. Which size catheter would be most appropriate to use?
12 French
16 French
18 French
22 French
An older adult male patient needs to have a condom catheter applied. An appropriate technique is to:
shave the perineal area before beginning.
apply povidone iodine to the penis before catheter application.
apply an adhesive strip in a circle around the base of the penis.
leave 1 to 2 inches between the tip of the penis and the drainage part of the catheter.
A patient who underwent prostate surgery is admitted to the surgical unit with a catheter that is used to provide continuous irrigation. The nurse recognizes this catheter is a(n):
Alcock.
Malecot.
Coudé catheter.
de Pezzer catheter.
A nurse is cleansing the perineal area of a female patient who is having a urinary catheter inserted. The nurse should use the last povidone iodine–soaked cotton ball to cleanse downward over the:
urinary meatus.
left labia.
right labia.
perirectal area.
When attempting to catheterize a male patient, there is resistance to catheter insertion. The nurse’s initial intervention should be to:
withdraw the catheter and start over.
ask the patient to take a deep breath.
ask the patient to bear down and hold his breath.
ask that the patient lie on the right side.
A patient has just had a urinary drainage catheter removed. The nurse plans to measure intake and output for this patient for another:
1 to 2 hours.
4 to 6 hours.
6 to 8 hours.
12 to 24 hours.
A male patient who suffered a spinal cord injury is learning to perform self-urinary catheterization before being discharged to home. The statement made by the patient that indicates more instruction is needed is:
It is a sterile procedure.
The catheter should be pinched before it is withdrawn.
The penis is lifted to a 60- to 90-degree angle for catheter insertion.
The procedure is done sitting on the toilet.
An adult patient has an order to have his urinary catheter irrigated with normal saline. The nurse plans to draw up how much solution into the sterile irrigation syringe?
1 to 20 mL
20 to 30 mL
30 to 40 mL
50 to 60 mL
A nurse irrigating a patient's indwelling urinary catheter should instill normal saline as ordered, and then:
unclamp the tubing and lower the collection bag.
massage the patient's bladder.
ask the patient to take a deep breath and hold it.
keep the tubing clamped for 30 to 45 minutes.
A nurse is reinforcing instructions about Kegel exercises with a female patient. An appropriate instruction is to:
do the exercises 12 times each day.
hold each muscle contraction for a count of 3 seconds.
tighten the abdominal muscles.
tighten the pelvic muscles.
A nurse is documenting the removal of a urinary drainage catheter from an assigned patient. If the catheter is removed at 9:00 AM, the nurse recognizes that the patient is due to void by:
11:00 AM.
12 noon.
5:00 PM.
9:00 PM.
A patient with a history of cystitis had surgery 24 hours ago and is now unable to void. A bladder scan indicates that he has approximately 400 mL of retained urine. The nurse anticipates that the least invasive intervention the primary care provider will order would be:
inserting an indwelling Foley catheter.
monitoring intake and output.
obtaining a midstream specimen.
applying Crédé maneuver to the bladder.
A nurse is caring for a patient with prostate enlargement who has an indwelling catheter. As the nurse is attaching a portion of the catheter to the patient's abdomen, the patient asks why this is being done. The correct response is:
Taping the catheter to your abdomen will prevent pulling on the meatus.
The catheter can't be pulled out if it is taped to your abdomen.
Taping it in this way enhances the draining of your bladder.
This will prevent the Foley catheter from kinking.
A nurse instructing a female patient on obtaining a clean catch urine specimen should stress:
to spread the labia apart and clean the center area first.
to catch the middle portion of urine after voiding a small amount into the toilet.
to carefully collect the urine in the container as soon as the urine stream starts.
to fill the urine cup to the brim to ensure an adequate sample.
A patient is being assessed for a possible urinary tract infection in the outpatient clinic. Before sending a urinalysis specimen to the laboratory, the nurse collects a small amount of urine in order to perform a dipstick test in order to detect:
protein.
glucose.
leukocytes.
ketones.
Nurses in a long-term care facility are developing a prevention program to eliminate catheter acquired infections (CAUTI). The rationale for this program includes which of the following?
Medicaid will no longer reimburse for this complication.
CAUTIs are considered an indicator of adequate care.
CAUTIs result in 45% of hospital-acquired infections every year.
Nursing interventions have been proven to have little or no effect on the number of urinary infections.
A nurse instructing a patient about how to prevent recurrent cystitis would include the need to: (Select all that apply.)
consuming more citrus fruits and juice.
emptying the bladder every 2 to 3 hours.
wiping the rectal area from front to back after a bowel movement.
increasing fluid intake to 2500 to 3000 mL/day.
wearing cotton underwear.
A patient's urinalysis results are available. Which of the following are considered normal characteristics? (Select all that apply.)
Straw colored
Specific gravity (SpG), 1.015
pH, 6.0
RBCs, more than 1 per high power field
Cloudy appearance
The nurse should provide enough hydration for the patient so that the patient can void at least every (a) hours.
The nurse has assessed that a patient's stool has changed from brown to dark black and sticky. The nurse suspects:
blockage of the bile duct.
blockage of the pancreatic duct.
recent excessive intake of milk products.
presence of occult blood.
The nurse has documented that a patient has had two episodes of steatorrhea, which means the character of the stool is:
hard and clay colored.
frothy and foul smelling.
very liquid and streaked with blood.
soft and filled with mucus.
The nurse should plan interventions to combat constipation in a patient:
being treated for diabetes mellitus.
who has a routine order for Metamucil.
who just completed barium studies of the bowel.
with orders to ambulate with assistance.
An older adult patient who routinely takes the bulk forming laxative psyllium (Metamucil) is counseled by the home health nurse that in order to prevent constipation and possible fecal impaction, this patient should be sure to take:
extra vitamin C.
a fat-soluble vitamin.
the medication with a large amount of fluid.
an over the counter antacid.
A patient calls the nurse at the health clinic and reports that since his trip to Mexico, he has been experiencing diarrhea. The nurse suggests he try the antidiarrheal drug:
docusate sodium (Colace)
loperamide (Imodium)
polycarbophil (FiberCon)
senna (Senokot)
An older adult resident in a long-term care facility has experienced constant diarrhea for 3 days and is now exhibiting signs and symptoms of dehydration. The nurse initiates an intervention to offer small amounts of ________ frequently.
Ginger Ale
Kool-Aid
Cola
A patient who has started antibiotic therapy is having diarrhea as a side effect of the medication. The nurse should encourage the patient to eat:
yogurt
raisins
gelatin fruit flavored dessert (eg, Jell O)
poultry
The nurse caring for a patient with lactose intolerance would anticipate the need to offer interventions for:
diarrhea
steatorrhea
constipation
hemorrhoid discomfort
A nurse has performed abdominal assessments on four patients. After reviewing the findings, the nurse is least concerned about problems with bowel elimination for the patient with:
abdomen nondistended, firm, with hypoactive bowel sounds in all four quadrants.
abdomen nondistended, soft, with active bowel sounds in all four quadrants.
abdomen distended, firm, with hypoactive bowel sounds in all four quadrants.
abdomen distended, soft, with hyperactive bowel sounds in all four quadrants.
A nurse is monitoring bowel elimination of a patient who has a history of constipation. The nurse implements measures to assist with bowel elimination if the patient has not had a bowel movement within how many days?
5
3
2
1
A patient has just completed a series of upper gastrointestinal tract radiographs that involved the use of barium as a contrast agent. Which measure will this patient need to help excrete the barium?
Diuretics and fluid restriction to 1.5 L
Diuretics and fluid intake increased to 3.5 L
Laxatives and fluid restriction to 1.5 L
Laxatives and fluid intake increased to 3.5 L
An ambulatory clinic patient telephones to report diarrhea and to ask for advice on medication to manage it. The best response by the nurse is, "Do not use antidiarrheal medication for longer than:
24 hours without calling back for an appointment.
48 hours without calling back for an appointment.
72 hours without calling back for an appointment.
96 hours without calling back for an appointment.
There is an order to administer a cleansing enema to an adult patient before bowel surgery. The nurse will fill the enema bag with how many milliliters of fluid for this procedure?
750 to 1000 mL
300 to 500 mL
200 to 300 mL
50 to 150 mL
A patient who is badly constipated has just received an oil retention enema. The nurse encourages this patient to try to hold the enema for at least how long before trying to have a bowel movement?
1-3 hours
3-4 hours
4-6 hours
6-10 hours
A nurse is preparing a cleansing enema for an adult patient who is constipated and has not responded to laxative use. Before giving the enema, the nurse should:
cool the solution to 70° F.
warm the solution in the microwave.
keep the solution at room temperature.
warm the solution to 105° F.
A patient scheduled for bowel surgery has an order to receive enemas until clear. The nurse is aware that no more than three enemas should be given because:
repeated enemas may cause more flatus.
the patient may develop an irritated rectum.
repeated enemas may cause electrolyte imbalance.
the patient may develop severe diarrhea.
A nurse is digitally removing a fecal impaction from a patient. The nurse should stop the procedure immediately and take corrective action if the patient's:
blood pressure increases from 110/84 to 118/88 mm Hg.
pulse rate decreases from 78 to 52 beats/min.
respiratory rate increases from 16 to 24 breaths/min.
temperature increases from 98.8° F to 99.0° F.
A nurse is reinforcing education with a patient who will begin a bowel training program. An intervention this program does not include is:
regularly scheduled time for toileting.
fluid intake of at least 1500 mL daily.
use of a suppository.
use of an enema.
A nurse is assisting a patient with a new continent ileostomy to catheterize the internal reservoir to drain the ileostomy. When the catheter meets resistance from the internal valve, the nurse should:
have the patient take a deep breath and apply gentle pressure over the area.
withdraw the catheter and start again with a new one.
ask the patient to bear down and hold her breath.
coat the opening with petroleum jelly or a water soluble lubricant.
A patient with a new colostomy should have the hole in the faceplate cut to allow _____ inch around the stoma.
1"
1/8"
1.25"
1.5"
A nurse is caring for a patient who had bowel surgery 3 days ago and is now beginning to have a well-functioning ostomy. The ostomy drainage bag should be emptied whenever it is:
one fourth full.
one half full.
three fourths full.
full.
A patient with a colostomy asks about foods that can be eaten that will reduce odor in the ostomy drainage bag. The most informative response by the nurse is to say that ostomy odor can be decreased with the intake of:
buttermilk
eggs
cucumbers
beans
The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, "I am so scared." The nurse's most supportive response would be:
Surgeries like yours are very safe.
What about your colostomy scares you?
Why are you scared?
Sounds like someone has been telling you horror stories.
The nurse reminds the patient that digestion of food is a complex process with much of the food breaking down in intestines. The small intestine functions to:
reabsorb sodium and chlorides.
propel waste material toward the anus.
digest and absorb nutrients from food
return water from the waste material to the bloodstream.
The nurse caring for a patient who had a colostomy 2 days ago assesses slight bleeding around the stoma when the area is cleansed, colostomy bag filled with gas, pale stoma, and a reddened area under the adhesive of the appliance. The assessment that should be reported immediately is the assessment pertaining to the:
skin irritation.
bleeding around the stoma.
amount of gas in the bag.
pale stoma.
The patient asks the nurse how an ileostomy differs from a colostomy. The most informative response by the nurse would be that:
an ileostomy is performed to remove stool from the colon, whereas a colostomy is the removal of lower portions of bowel, diverting intestinal contents.
an ileostomy has effluent that is more formed, whereas a colostomy has effluent that is liquid.
a colostomy is an opening into the colon, whereas an ileostomy is an opening at the ileum.
an ileostomy requires irrigating, whereas a colostomy requires catheterizing.
The patient with the new colostomy is concerned about how to control diarrhea of the effluent. The nurse suggests that diarrhea can be controlled by the intake of:
cheese
onions
raw vegetables
beans
The nurse instructs the patient who has had an ileostomy to modify the diet to include: (Select all that apply.)
increase the protein intake.
choose foods that are high in calories.
select foods that have a milk base.
eat raw vegetables and fruits.
include whole grain products in diet daily.
The nurse instructs a patient with a new colostomy against eating food that may cause an obstruction. These foods include: (Select all that apply.)
spicy foods
whole kernel corn
banana
tomatoes
shrimp
The gastrocolic reflex initiates (a) .
The nurse assesses a pale, light gray stool and recognizes that the cause of this abnormal color is due to an obstruction in the (a) duct.
The nurse reminds a group of older adults that a colonoscopy is recommended every (a) year(s) after the age of 45.
