WorksheetsExam 3
Total questions: 60
Worksheet time: 30mins
A nurse is collecting a midstream urine specimen. Which step is essential?
Collect the first voided urine
Avoid cleaning the perineal area
Collect urine after starting the stream
Store the sample at room temperature
What term describes the presence of glucose in the urine?
Proteinuria
Hematuria
Glycosuria
Ketonuria
What is the minimum acceptable urine output per hour for an adult?
10 mL
20 mL
30 mL
50 mL
Which type of incontinence is associated with sudden urgency?
Stress
Urge
A client with a hip fracture cannot elevate their pelvis. Which elimination aid should the nurse provide?
Regular bedpan
Fracture pan
Commode
Urinal
A nurse is reviewing a client’s lab work. Which finding best supports the presence of chronic protein malnutrition?
Hemoglobin 13.4 g/dL
Serum albumin 2.8 g/dL
Transferrin 225 mg/dL
Glucose 88 mg/dL
Which nursing intervention is most effective in preventing aspiration when assisting a client with dysphagia during meals?
Encouraging slow chewing
Positioning the client upright
Thickening liquids
Supervising during intake
Which dietary instruction is most appropriate for a client on a full liquid diet?
You can have creamed soups and pudding.
You may include toast and yogurt.
Clear fruit juices are your best option.
All fruits and vegetables are encouraged.
A vegetarian asks how to meet daily protein needs. Which response shows the best understanding of protein complementation?
Drink soy milk at every meal.
Combine beans with rice for complete protein.
Eat plenty of green leafy vegetables.
Add nuts to your breakfast.
Which of the following is the most appropriate nursing response when evaluating a client with a BMI of 17.5?
This BMI may place you at risk for osteoporosis.
You're slightly underweight; increase calories.
This puts you within a healthy weight range.
Consider tracking your diet to ensure proper balance.
A nurse is caring for a client prescribed a mechanical soft diet. Which menu item best aligns with this dietary order?
Baked chicken breast with roasted vegetables
Cooked oatmeal with mashed bananas
Fresh garden salad with vinaigrette
Toast with scrambled eggs
Which lab result should concern the nurse most in an older adult with signs of poor nutritional status?
Triceps skinfold: 6 mm
Hemoglobin: 13.2 g/dL
Serum albumin: 2.9 g/dL
Glucose: 96 mg/dL
A client reports eating once daily and recent unintentional weight loss. What is the nurse’s best first step?
Obtain a serum albumin level
Calculate BMI
Document food preferences
Request a dietitian consult
Which combination provides the best example of protein complementation for a vegan client?
A. Eggs and cheese
B. Brown rice and black beans
C. Yogurt and granola
D. Tofu and vegetable stir-fry
A nurse is teaching a client with limited income about healthy food choices. Which statement best reflects a practical approach?
Buy organic produce to reduce pesticide exposure.
Purchase vitamin supplements from health stores.
Combine dried beans and rice for complete protein.
Eat more packaged meat substitutes.
Which anthropometric measurement is most useful in monitoring muscle wasting in a long-term care client?
BMI
Midarm circumference
Waist-to-hip ratio
Height
What instruction is most accurate when educating a client about reading nutrition labels?
Check the cholesterol first.
The %DV helps you compare nutrient values.
Ignore calories; focus on vitamins.
Use sodium content to guide sugar intake.
Which of the following would the nurse expect to find in a malnourished client’s physical assessment?
Healthy gums and moist skin
Thick, shiny hair and alert cognition
Dull eyes, dry skin, and poor turgor
Normal reflexes and strong hand grip
Which is the strongest rationale for including exercise in the care plan of a sedentary older adult?
Prevents falls and fractures
Promotes social interaction
Increases appetite and nutrient absorption
Reduces boredom in long-term care settings
Which scenario most clearly supports a diagnosis of emaciation?
Client with BMI of 20, appetite loss, and low protein intake
Client with hollow facial features, visible ribs, and BMI of 16
Client with mild weight loss and low triceps skinfold
Client with normal labs but low fluid intake
What is the nurse’s most appropriate response to a client on a clear liquid diet who is requesting orange juice?
Yes, that is allowed.
Orange juice is okay if diluted.
Let me ask the physician.
Orange juice is not clear and not permitted.
Which client statement indicates a need for further teaching about soft diets?
I can have well-cooked vegetables.
I’ll avoid spicy and fried foods.
I can eat raw celery with peanut butter.
I’ll mash my potatoes before eating.
Which strategy is most effective when feeding a client with advanced dementia?
Serve a full tray with all food groups visible
Feed quickly before the client becomes distracted
Offer finger foods one at a time in a calm setting
Use loud verbal cues and reminders
What factor most contributes to nutritional deficits in older adults?
Reduced kidney function
Limited socialization during meals
Frequent dental checkups
Adequate access to supplements
A client reports avoiding milk due to lactose intolerance. Which substitution best ensures calcium intake?
Drink orange juice
Eat green leafy vegetables
Eat hard cheese and yogurt
Drink flavored water
A nurse is teaching a new staff member how to prevent injury while lifting patients. Which technique should the nurse emphasize first?
Bend at the waist and keep the load close
Keep knees straight and pivot with your back
Widen your stance and lift with your legs
Hold your breath while lifting to stabilize the core
A client with limited mobility is repositioned every two hours. Which nursing goal does this intervention most directly support?
Enhances venous return
Prevents contractures
Reduces skin breakdown
Increases independence
A nurse notices that a client's feet are plantar-flexed while in the supine position. What device is most appropriate?
Pillow under knees
Footboard at base of bed
Bed cradle over feet
Rolled towel behind calves
A nurse is about to reposition a client. What should be done first?
Elevate the bed to waist level
Roll the client toward the nurse
Place a drawsheet under the client
Assess the client’s ability to assist
A client lies flat in bed for extended periods. Which condition is most likely to result?
Urinary retention
Foot drop
Hypoglycemia
Constipation
A nurse evaluates a patient’s sitting posture. Which finding requires immediate correction?
Hips at 90° with feet flat on floor
Shoulders level and relaxed
Buttocks unsupported by chair
Knees slightly below hip level
Which action is most effective in preventing musculoskeletal injury during a lateral client repositioning?
Pulling the client with a drawsheet alone
Using a friction-reducing roller sheet with two caregivers
Dragging the client toward the edge of the bed
Placing pillows under the arms before turning
A nurse prepares to move a client up in bed. Which bed adjustment is most important before moving?
Raising the head of the bed
Raising the bed to elbow height
Lowering the bed to the floor
Locking the side rails up
Which scenario indicates the best use of a trochanter roll?
A client with incontinence
A client with lower back pain
A client recovering from hip surgery
A client with foot drop
A nurse is teaching a client about Fowler’s position. Which statement indicates understanding?
I’ll lie flat to increase lung expansion.
Fowler’s position helps me breathe easier.
My legs will be elevated above my chest.
My feet will point downward to reduce edema.
A nurse is preparing to reposition a dependent client using a drawsheet. What should the nurse do before beginning the move?
Place pillows along the client’s side
Apply lotion to the client’s back
Ensure bed height is at waist level
Pull the drawsheet toward the head of the bed
Which finding would most concern the nurse when assessing the effects of immobility in a client?
Decreased bowel sounds
1+ edema in ankles
Asymmetric calf circumference
Pale skin at the sacrum
A nurse is caring for a client using a low-air-loss bed. Which statement best explains its purpose?
It evenly distributes pressure to prevent ulcers.
It keeps the patient in a floating position.
It reduces incontinence by wicking away moisture.
It stabilizes the spine during movement.
Which body system benefits most directly from using proper ergonomics during client transfers?
A. Musculoskeletal
B. Neurological
C. Cardiovascular
D. Integumentary
Which position would the nurse place a client in to relieve sacral pressure?
Prone
Sims’
Lateral oblique
Supine
A client requires frequent repositioning. Which tool is most appropriate to reduce friction?
Transfer board
Trapeze bar
Roller sheet
Trochanter roll
Which action is most appropriate when transferring a partially weight-bearing client from bed to chair?
Use a mechanical lift
Apply a gait belt and pivot assist
Request help from a second nurse
Instruct client to push off bed rails
Which nursing action best promotes spinal alignment in a client positioned laterally?
Use two pillows under the head
Flex the lower leg and extend the top leg
Place a pillow between the knees
Tuck the arms under the client’s body
What is the primary goal of using a trapeze bar for a client in bed?
To prevent foot drop
To reduce shoulder dislocation
To assist with repositioning and upper body strength
To provide psychological stimulation
A nurse places a hand roll in a client’s palm. What is the intended outcome?
Reduce wrist extension
Maintain hand alignment and prevent contractures
Improve sensory stimulation
Support circulation in the digits
A nurse repositions a client and observes blanchable redness on the hip. What action is most appropriate?
Document the finding and return in 2 hours
Place a foam dressing over the area
Offload pressure and reposition more frequently
Apply a warm compress for circulation
A nurse is transferring a 300-lb non-weight-bearing client from bed to chair. What is the safest strategy?
Two-person assist and gait belt
Use of transfer board and roller sheet
Mechanical lift with two trained staff
Slide sheet with high Fowler’s position
Which client is best suited for the prone position?
Post-abdominal surgery
Spinal cord injury requiring airway clearance
COPD patient on oxygen
Client with nausea and vomiting
Which positioning error most increases the client’s risk for pressure ulcer development?
Using a pillow under the knees
Placing the client flat in bed
Elevating the head of bed to 90°
Flexing the knees and hips slightly
The nurse is evaluating the effectiveness of a positioning schedule. Which finding indicates positive outcome?
No skin redness over bony prominences
Slight non-blanchable redness over elbows
Family reports client is sleeping more
Moisture barrier cream applied twice daily
Which observation should the nurse prioritize when evaluating a client's voiding pattern?
Urine color and clarity
Time of last void
Urine output of 35 mL/hour
Voiding every 6–8 hours
Which urinary condition most warrants immediate intervention?
Glycosuria in a diabetic
Residual urine of 55 mL
Anuria in the last 12 hours
Frequency and urgency in an older adult
The nurse provides instructions for a midstream urine specimen. Which client action indicates accurate understanding?
I will urinate completely into the container.
I'll use the first part of my urine stream.
I will cleanse and then catch urine midway.
I'll collect urine and refrigerate it until tomorrow.
A client voids 300 mL but experiences urgency 10 minutes later. What is the most likely cause?
Polyuria
Urinary retention
Nocturia
Urge incontinence
Which characteristic most accurately defines polyuria?
Urine output greater than 3,000 mL/day
Voiding 5 times a day
Frequent small voids with burning
Nighttime urination twice per night
Which nursing action best prevents urinary stasis in a bedridden client?
Encouraging 2 liters of fluid intake
Limiting voiding to 4 times/day
Elevating the foot of the bed
Using a fracture pan every 6 hours
A client’s urinalysis reveals ketonuria. What is the nurse’s best clinical response?
Encourage more rest
Notify the provider of possible diabetes or starvation
Increase the client’s sodium intake
Reassess fluid intake
What does a positive finding of protein in the urine most likely indicate?
Urethral irritation
Urinary tract infection
Glomerular dysfunction
Fluid overload
Which client is most at risk for developing stress incontinence?
70-year-old with Parkinson’s disease
38-year-old who gave birth vaginally to 5 children
50-year-old with prostate enlargement
60-year-old with chronic urinary retention
What is the most effective strategy for managing functional incontinence?
Provide privacy
Offer bedpan every 2 hours
Use bladder retraining program
Improve access to toileting
