Exam Revision Guide Part 4 (75-100)

Question 75 The nurse is preparing a client for a diagnostic testing of urinary function. The nurse must make sure a consent form is on the client’s chart for this test: Urinalysis Renal X-ray Correct Answer IV pyelogram Urine culture An intravenous pyelogram requires a consent be signed by the client because it involves the intravenous injection of contrast dye by the radiologist. The other tests listed do not require special consent. Question 76 The nurse receives intake and output reports on several clients from the nursing assistant. Select the output which the nurse should report to the provider. 120 mL in 4 hours 500 mL in 6 hours 300 mL in 4 hours 100 mL in 6 hours Normal urine output is at least 30 mL per hour. 100 mL in 6 hours is 16 mL/hr and is too low. Question 77 A client reports to the nurse that they feel the need to urinate but can’t. Select the priority nursing intervention for this client. Perform a bladder scan Palpate the bladder for distention Collect urine for a urinalysis Perform a straight catheterization The nurse should first palpate the bladder for distention. If distention is suspected, a bladder scan can be performed. Urinalysis and catheterization both require provider order. Question 78 The nurse is assigning care to a nursing assistant (NA) for a client with an indwelling urinary catheter. The nurse instructs the NA to do this in order to best prevent catheter associated urinary tract infection: Tape the catheter to the upper thigh Offer the client oral fluids every hour Use medical asepsis to change the drainage bag Correct Answer Perform good perineal care daily Keeping the perineum and catheter clean is the best way to prevent a CAUTI in a catheterized client. Question 79 A client with this type of urinary diversion requires the nurse to instruct them how to selfcatheterize. Ileal conduit Correct Answer Continent urinary reservoir Nephrostomy Ileostomy A continent urinary reservoir is a pouch created by the surgeon for the purpose of collecting urine in the absence of a bladder. The client must learn how to perform self-catheterization in order to drain the pouch as instructed. Question 80 The nurse can delegate this intervention to the nursing assistant. Empty and record output from a urinary drain bag Remove a foley catheter once the balloon is deflated Change the drain bag on a foley catheter Perform a straight catheterization to collect a urine sample The nursing assistant may only empty and record output from a urinary drain bag. Any maintenance or handling of the catheter itself is a nursing responsibility. Question 81 While caring for a post-procedure client who underwent a cystoscopy a few hours ago, the nurse notes pink-tinged urine in the client’s urinal. Select the priority nursing action. Immediately contact the provider who performed the procedure Empty the urinal and record the amount voided Encourage the client to restrict oral fluids Start IV fluids to rehydrate the client Pink-tinged urine is a possible after-effect of cystoscopy if the provider removed tissue for pathology or the bladder lining was irritated by the scope. The nurse would need to contact the provider who performed the procedure only if blood was noted in the urine. The client would be instructed to drink plenty of oral fluids, if allowed, to flush the bladder. Question 82 A nurse caring for an older adult male client understands that this is an expected physiological change. Foul smelling urine Brown urine Renal calculi Decreased bladder capacity Older adults experience decreased bladder capacity. Foul smelling urine indicates a urinary tract infection and is not normal. Brown urine indicates bilirubin being spilled in the urine and this is not normal. Renal calculi is a pathological condition. Question 83 The nurse is teaching a group of home care providers about caring for the older adult with urine incontinence. The nurse includes this statement in the teaching: It is best to have the client wear adult diapers Unless contraindicated, restrict oral fluids to 1 liter per day Kegel exercises are not effective for older adults to prevent incontinence Establishing a toileting plan can help limit episodes of incontinence Toileting a client every two hours can help them establish a schedule that will reduce the episodes of incontinence. The client should only wear adult diapers if there is no success with toilet training. Restricting fluids is not an appropriate intervention and may cause harm. Older adults can benefit from Kegel exercises to reduce the incidence of incontinence. Question 84 A nurse is doing preoperative teaching for a client about to undergo abdominal surgery. The nurse will insert a foley catheter prior to taking the client to the preoperative area. The best rationale for this intervention is what? To prevent bladder distention during surgery To prevent the client from voiding on the surgical table To collect urine specimens during the surgery To maintain the client’s comfort throughout the procedure A surgeon will often prescribe a foley catheter be placed prior to abdominal surgery in order to prevent bladder distention and problems visualizing the abdominal cavity. Question 85 The nurse is caring for a female client who requires the insertion of an indwelling urinary catheter. The nurse will place the client in this position to best facilitate catheter insertion. Semi-fowlers Supine Correct Answer Dorsal recumbent Sims The client is placed in the dorsal recumbent (supine with the knees bent) position to facilitate insertion of the foley catheter. Question 86 The nurse is caring for a post-operative client and notes a moderate amount of serous drainage on the dressing 24 hours after surgery. What is an appropriate nursing action? Notify the surgeon that you suspect the client has an infection Leave the dressing intact Remove the dressing and leave the wound open to air Change the dressing The nurse should change the dressing and apply a dry sterile dressing. It is not necessary to notify the surgeon for serous drainage unless there is a foul odor. The wound should not be left open to air to prevent bacteria from entering the incision site. Unless otherwise instructed, the dressing should not be left in place. This will encourage the growth of bacteria that could enter the incision. Question 87 The nurse is assessing a wound that is 75% covered with eschar. What treatment does the nurse expect to be ordered? Clean several times a day with normal saline and sterile gauze Apply a dry sterile dressing daily to the wound Correct Answer Prepare the client for surgical debridement Stage the wound as a Stage IV pressure ulcer Eschar on a wound requires mechanical debridement which will be done by the provider. Cleaning with sterile saline and sterile gauze will not help remove the eschar. Applying a dry sterile dressing will not help remove the eschar which must be debrided in order for the wound to heal. Wounds cannot be staged until all slough and eschar is removed. Question 88 The nurse is preparing to administer enteric feeding through a nasogastric tube. What does the nurse do after checking the placement of the tube? Position the client with head of the bed elevated to 20 degrees Chill the feeding solution before giving it Flush the tube with 30 ml of sterile or tap water Offer the client sips of water during the feeding The nurse should flush the tube with 30 mL of water before starting the feeding to ensure tube patency. Enteric feedings should be given at room temperature. The client should not take anything by mouth unless allowed by the provider. Question 89 The nurse is inserting a nasogastric tube when the client begins to gag. What does the nurse do next after stopping the insertion? Have the client take a deep breath Check the mouth for a curled tube Administer an antiemetic Remove the tube and call provider The nurse should look into the mouth to see if the tube has curled against the palate causing irritation of the uvula and gagging. Having the client take a deep breath or giving an antiemetic is inappropriate until the nurse has assessed the tube placement. It is not necessary to remove the tube nor call the provider unless, when the tube is finally placed correctly the gagging continues. Question 90 The nurse is preparing to insert a straight catheter into a male client. Which action is appropriate? Ask the client to void into a sterile container Insert the catheter slowly if the client has an erection Hold the penis parallel to the scrotum during insertion Correct Answer Retract the foreskin if present before cleaning the glans The nurse must retract a foreskin if present to clean the glans. Following insertion of the catheter the foreskin should be replaced to it’s original position. A client does not void during the straight catheterization. The client will void if the specimen is a clean-catch. The penis is held perpendicular to the scrotun. The nurse should never insert a catheter to an erect penis to avoid injury to the urethra. Question 91 The nurse is teaching teen-age girls about nutrition. Which nutrient do teen girls need more of that teen boys do not? Iron Calcium Protein Potassium Teen-age girls need more iron than do teen boys due to the monthly iron loss caused by menstruation. Question 92 The nurse is assessing an older client for dysphagia. What sign indicates the client may have dysphagia? Memory loss Constipation Drooling Weight gain Drooling is a sign the client may have dysphagia. Other signs include coughing during meals, choking and anxiety when offered foods. Memory loss, constipation and weight gain are not signs of dysphagia. Question 93 The nursing assistant is feeding a client with dysphagia. What can the nurse teach the assistant to help prevent choking during feeding? Correct Answer Check the mouth for food after feeding Select hot, pureed foods to improve appetite Offer sips of ice water through a straw Use only finger foods the client can feed themselves The nursing assistant should frequently check the mouth for food not swallowed to prevent aspiration. Hot foods might cause burns to the mucous membranes. Drinks should not be taken with a straw which increases the risk of aspiration. Finger foods may not be the proper consistency for a client with dysphagia. For instance, grapes can cause choking. Question 94 A client tells the nurse they are still constipated despite increasing fiber in their diet. What is an appropriate question to ask the client? What kind of fiber are you eating? Correct Answer How many glasses of water do you drink a day? What time of day are you eating the most fiber? Are you eating cooked or raw fiber? The nurse should find out if the client has also increased their intake of fluids. Fiber alone can make constipation worse. It doesn’t matter the type of fiber or when the client eats it as long as they increase fluid consumption. Question 95 The nurse is providing a bath for a client who is bedbound. The nurse understands these care benefits from good hygiene: {Select all that apply} Provides comfort Prevents infection Prevents pressure ulcers Provides rest Promotes communication Question 96 The nurse is teaching a group of home care workers about pressure ulcer formation. Choose the condition(s) that place a client at risk for pressure ulcer formation. {Select all that apply} Fecal incontinence Dehydration Wound infection Correct Answer Malnutrition Correct Answer Use of an assistive device Question 97 A nurse is caring for a group of clients. Choose the client most likely to suffer from inadequate oxygenation {Select all that apply} Accident victim with heavy blood loss Client with blood clots in the lungs Teen with seasonal allergies Child recovering from drowning Older adult with heart failure A, B, D and E are correct. A teen with seasonal allergies has symptoms confined to the upper airway and not likely to suffer inadequate oxygenation. Question 98 A client suddenly starts to slide down to the floor while ambulating. Choose the correct actions by the nurse to prevent injury to both themselves and the client. {Select all that apply} Stand in front of the client to prevent foward falling motion Stand with feet apart in a wide base behind the client Push out against the client to ease their fall Extend one leg out to allow the client to slide against it Bend your knees and lower the client slowly to the floor Because the client is sliding to the floor the safest way to ease them down is to perform actions B, D and E. Question 99 The nurse is preparing to collect a sterile urine specimen from a client’s foley catheter. Choose the correct actions the nurse will perform. {Select all that apply} Wash hands and apply clean gloves Correct Answer Clamp the drain tube for 30 minutes Use a 10 mL syringe to withdraw urine from the drain port Transfer the urine to a sterile specimen container Correctly label the specimen with client’s name, date of birth, the date, time and your initials Question 100 The nurse is helping a client select items for lunch from a clear liquid diet menu. Which items are allowed on this diet? {Select all that apply} Pudding Chicken broth Jello Cream of wheat Correct Answer Black coffee