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WorksheetsExam 3 Review (Administration, Elimination, Diagnostics)
Total questions: 98
Worksheet time: 3hrs 16mins
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 A 16%
Random Blood Sugar (RBS) 112 mg/dL
Lactate dehydrogenase (LDH) 55 units/L
Erythrocyte sedimentation rate (ESR) 14mm/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/mm
Serum cholesterol 175 mg/dL
Albumin 1.4 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 sec
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 w/ 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
Fiberoptic 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
Ineffective coping 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
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 patient for a gag reflex
Provide a small cup of ice water w/ a straw
Keep the patient NPO
The nurse is caring for a patient who will be undergoing bone marrow biopsy. Which statement by the patient indicates that additional teaching is needed?
I will count the ceiling tiles when the doctor inserts the numbing medicine.
I will take acetaminophen later today if the site becomes uncomfortable.
I will squeeze your hand to help calm my fears about the test.
I will keep the biopsy site clean and dry for the next 24 hours.‖
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 healthcare 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 3
Platelet count 450,000/mm
Serum uric acid level 1.7 mg/dL
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 who is having blood drawn as part of preoperative testing. Which step is the most important to ensure the safety of the patient and the nurse?
Ensuring that the tourniquet is not left in place for too long
Using the smallest possible needle for venipuncture
Properly disposing of the needle after the specimen is obtained
Making sure that all of the collection tubes are filled completely
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 who is anemic. Which CBC test results demonstrate that the patient‘s treatment plan is effective and the anemia is resolving? (Select all that apply.)
Red blood cell count (RBC) 5.8 million/mm3
Hematocrit (HCT) 25%
Hemoglobin (HGB) 14 g/dL
White blood cell count (WBC) 4500/mm^3
Platelet Count (PLT) 255,000/mm^3
The nurse is caring for a patient who has been having abdominal pain. The doctor suspects that the patient may have an abdominal aortic aneurysm. Which tests would confirm the doctor‘s suspicion? (Select all that apply.)
Magnetic resonance imaging (MRI) scan
Needle aspiration with biopsy
Fiberoptic endoscopy
Computed tomography (CT) scan
Flexible sigmoidoscopy
The nurse is caring for a patient who is undergoing a liver biopsy. Which interventions will be included in the patient‘s care plan for the diagnosis of risk for infection: r/t invasive diagnostic procedure? (Select all that apply.)
Monitor for and report redness, warmth, discharge, or fever promptly to the
physician.
Carefully maintain the sterile field during the biopsy procedure.
Teach patient how to care for the biopsy site when procedure is completed.
Provide a supportive, caring presence to minimize patient anxiety.
Provide information about the pathophysiology and treatment options for liver
cancer.
The nurse is caring for a patient who needs to collect a 24-hour urine specimen at home. Which steps of specimen collection may be delegated to the assistant? (Select all that apply.)
Label the urine container and lab slips with the patient‘s name and information.
Assess the patient‘s ability to collect the specimen as required.
Explain the procedure to the patient.
Obtain the urine container from the utility room or laboratory.
Transport the specimen to the laboratory once it is collected.
The nurse is caring for a patient who is taking medication that is toxic to the liver. Which laboratory test results will be reviewed by the nurse to ensure that the patient‘s liver is tolerating the medication without damage to the organ? (Select all that apply.)
Alanine aminotransferase (ALT)
Alkaline phosphatase (ALP)
Blood urea nitrogen (BUN)
Anti-nuclear antibody (ANA)
Erythrocyte sedimentation rate (ESR)
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 relive 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 PRO 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?:
MS Contin Morphine sulfate Extended release tablets, USP 15 mg
CII only
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 suspects that the patient is experiencing a drug toxicity rather than a side effect. Which question will the nurse ask to help confirm this suspicion?
When did you take your last dose of the medication?
Have you been taking extra doses of the medication?
Are you taking any other medications?
Have you ever taken this medication in the past?
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 to administer 15 mg of morphine liquid to the patient. How much morphine liquid will the nurse draw up to administer to the patient?
"Morphine sulfate oral solution (CONCENTRATE)
100 mg/5 mL
(20 mg/mL)
CII only"
0.5 mL
0.75 mL
1.3 mL
1.5 mL
The nurse is caring for a patient with multiple chronic illnesses who is having difficulty remembering to take multiple medications at the correct times. Which is the appropriate Nursing diagnosis for this patient?
Activity intolerance related to inability to take medications on time
Impaired health maintenance related to complexity of medication schedule
Risk for aspiration related to need to swallow many pills during day
Powerlessness related to inability to figure out medication dose times
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?
"Trexall Methotrexate tablets, USP 2.5 mg tablets
only"
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?
"Phenobarbital tablets, USP 15 mg
CIV only"
1 tablet
2 tablets
3 tablets
4 tablets
The nurse is caring for a patient who is NPO with a new PEG (percutaneous endoscopic gastrostomy) tube. Which of the patient‘s medications can the nurse administer through the tube? (Select all that apply.)
Ondansetron (Zofran) oral disintegrating tablet 8 mg q 8 hours PRN nausea
Cefaclor (Ceclor) for oral suspension 250 mg q 6 hours
Oxymorphone hydrochloride extended release (Opana ER) 40 mg q 12 hours
Phenytoin (Dilantin) chewable tablet 100 mg q 12 hours
Potassium chloride oral solution 20 mEq daily
The nurse identifies which medications that are to be administered via parenteral routes? (Select all that apply.)
Bisacodyl (Dulcolax) 10 mg suppository daily PRN constipation
Prochlroperazine (Compazine) 10 mg IM q 6 hours PRN nausea
Brimonidine (Alphagan) 0.1% solution 2 drops to each eye daily
Insulin lispro (Humalog) insulin 15 units subcutaneously ac meals
Fentanyl (Duragesic) 50 mcg transdermal patch apply every 72 hours
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 has diarrhea and identifies which priority nursing
diagnosis for this patient?
Lack of knowledge related to prescribed diet medications
Impaired nutritional intake related to poor appetite
Diarrhea related to excessive loss of fluid through stool
Anxiety related to incontinence with loose stools and need for clothing change
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.
he 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 x 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 has an ileostomy. Which Nursing diagnosis has the highest priority for the patient?
Impaired skin integrity r/t localized skin irritation from liquid stool
Social isolation r/t potential leakage of stool from ostomy appliance
Lack of knowledge r/t care and maintenance of ostomy appliance
Disturbed body image r/t presence of stoma and altered elimination
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 will undergo colonoscopy testing. Which intervention will the nurse include in the patient‘s plan of care for the day before the test?
Provide the patient with zinc oxide skin barrier cream for the perineal area.
Obtain an order for a gentle laxative to be given once the test is completed.
Carefully assess the patient‘s ability to swallow liquids through a straw.
Check the patient for allergies to shellfish and iodine-based contrast dyes.
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
Send the samples to the laboratory while they are still warm
Inform the patient that several stool samples will be needed
Use a sterile container when collecting stool samples
The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding b 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 after hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis Impaired self-toileting?
The patient will demonstrate safe transfer technique between wheelchair and toilet.
The call light will be answered promptly when the patient needs to use the toilet.
Toileting will be scheduled in the morning when the patient needs to defecate.
Toilet paper and handwashing items will be kept within easy reach of the patient.
The nurse is caring for a patient who is recovering from gastroenteritis. 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 patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient?
The patient will remain continent with no perineal skin breakdown.
The patient will state satisfaction with use of gait belt for toilet transfers.
The patient will regain ability to pull up clothing after using the toilet.
The patient will have privacy once properly positioned on the toilet.
A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor?
Water-soluble lubricant is applied to the end of the enema tubing.
The enema tubing is primed with solution that has been warmed.
The patient is positioned comfortably in the right side-lying Sims position.
The patient‘s bedpan is put at the bedside in preparation for use.
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
Application of skin protectant to the area surrounding the stoma
Determining which type of ostomy appliance to use
Assessing the stoma and incision for signs of infection or ischemia
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
Glass of apple juice
Coffee with cream and sugar
Lemon-flavored Italian ice
The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. The nurse recognizes which type of renal failure the patient most likely developed?
Prerenal
Renal
Postrenal
Mixed
The nurse is caring for a patient with a neurological condition that causes constant severe thirst, drinking fluids continuously, and voiding 3to 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 recently underwent ileal conduit surgery. Which nursing diagnosis is the highest priority for this patient?
Impaired sexual function related to changed body structure
Social isolation related to potential for accidental leakage of urine
Lack of knowledge related to care and maintenance of ostomy appliance
Disturbed body image related to presence of stoma and appliance
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 has developed kidney failure. Which test finding leads the nurse to contact the nephrologist and arrange for emergency hemodialysis?
Potassium level 6.8 mmol/L
Serum creatinine level of 2.8 mg/dL
Large amounts of protein in the urine
1500 mL of retained urine in the bladder
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 an incontinent male patient who has a deep decubitus ulcer on his sacrum. Which intervention will best manage the patient‘s urinary incontinence and facilitate healing of the ulcer?
Use of disposable absorbable incontinence briefs
Daily application of perineal barrier cream containing zinc oxide
Careful perineal care and application of a condom catheter
Insertion of a single-lumen straight urinary catheter
The nurse is caring for a patient who has urinary frequency. Which nursing diagnosis is the highest priority for this patient?
Impaired urination r/t occasional incontinence
Anxiety r/t living alone at home with nocturia
Risk for infection r/t urine contact with perineal area skin
Risk for fall-related injury r/t hurried trips to the bathroom during the day and
night
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 warmed sterile normal saline.
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?
a. Sudden leakage of urine when patient is unable to get to the toilet in timeb. Continuous urine flow from the bladder regardless of attempts to use the toilet
c. Leakage of urine from the bladder when the patient coughs, sneezes, or laughs
d. Leakage of urine because the patient is unable to indicate need to use the toilet
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 nurse is caring for a patient with an indwelling urinary catheter caused by severe prostate enlargement. Which is the priority nursing diagnosis for this patient?
Risk for infection r/t indwelling urinary catheter
Disturbed body image r/t presence of catheter
Risk for contamination r/t potential leakage of urine on clothing
Impaired urination r/t blockage of bladder outlet
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 with a history of type 1 diabetes. Which assessment finding indicates to the nurse that the patient may not be compliant with the diabetic treatment regimen?
The patient is always thirsty and frequently voids very large amounts of urine.
The patient‘s urine is very concentrated with a dark amber color.
The patient complains of throbbing flank pain and burning with urination.
The patient has urinary hesitancy and difficulty initiating a stream of urine.
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 with a history of arthritis, urinary incontinence and poor perineal hygiene practices. The patient has had four urinary tract infections in the past year. Which is the priority goal for the nursing diagnosis Impaired health maintenance for this patient?
a. The patient will be provided with educational materials about risks of urosepsis.
The patient will allow family members to assist with daily bathing and perineal
care.
The patient will discuss the possible consequences of frequent UTIs.
Regular home care nursing visits and follow-up telephone contact will be arranged.
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 patient is urinating more frequently than usual.
The patient is normally continent but has been incontinent twice.
The urine is concentrated and dark amber in color.
The nurse is caring for a male patient who will be performing intermittent self-catheterization at home. Which actions by the patient indicate the need for additional teaching about this procedure? (Select all that apply.)
Patency of the balloon is tested prior to insertion of the catheter.
The catheter is inserted another 2 inches after urine is seen in the tubing.
The catheter is carefully secured to the leg to prevent accidental removal.
Water-soluble lubricant is generously applied along the length of the catheter.
The foreskin is returned to its natural position after the catheter is removed.
The nurse is working with a new nursing assistant who is providing care to patients with urinary difficulties. Which actions by the nursing assistant indicates that additional teaching is required? (Select all that apply.)
The length of the urinary catheter is cleaned up to the patient‘s perineum.
A fresh condom catheter is applied every other day following careful perineal care.
The catheter drainage bag is disconnected in order to put pants on the patient.
Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter.
A urine sample is obtained from the drainage bag immediately after catheter insertion.
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.)
Keeping the urine collection container cool on ice
Dumping the urine from the patient‘s first void
Transporting the specimen to the laboratory for testing
Reminding the patient not to put toilet paper in the urine
Teaching the patient about sterile specimen collection
