Fundamentals of Nursing Exam 2 2024-2025. Questions & Correct Answers. Graded A+, Exams of Nursing

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Fundamentals of Nursing Exam 2 2024-

2025. Questions & Correct Answers.

Graded A+

1. The nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. What is the most appropriate action? a. Insert the tube quickly. b. Notify the health care provider immediately. c. Remove the tube and reinsert it when the respiratory distress subsides. d. Pull back on the tube and wait until the respiratory distress subsides. - ANSd Rationale: During the insertion of the nasogastric tube, if the client experiences difficulty breathing or any respiratory distress, withdraw the tube slightly, stop the tube advancement, and wait until the distress subsides. It is not necessary to notify the HCP immediately or remove the tube completely. Quick inserting the tube is not an appropriate action because, in this situation, it is likely that the tube has entered the bronchus. 10) A nurse is assessing a patient who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply) a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema - ANSb, c, d Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an elevated temperature, a

decrease in blood pressure, poor skin turgor, tachycardia, and weakened peripheral pulses. Peripheral edema results from a fluid overload. 11) While a nurse is performing a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Have the client hold their breath briefly and bear down b. Clamp the enema tubing c. Remind the client that cramping is common at this time d. Raise the level of the enema fluid container - ANSb Rationale: Clamp the enema tubing for 30 seconds to reduce intestinal spasms. Telling the client that cramping is common is non therapeutic and implies that the client must tolerate the discomfort and that the nurse cannot or will not do anything to ease it. 12) A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply) a. Warm the enema solution prior to instillation b. Position the client on the left side with the right leg flexed forward c. Lubricate the rectal tube or nozzle d. Slowly insert the rectal tube about 5 cm (2 in) e. Hang the enema container 61 cm (24 in) above the client's anus - ANSa, b, c Rationale: Warm enema solution because cold fluid can cause abdominal cramping, and hot fluid can damage the intestinal mucosa. Place the client on the left side with the right leg

flexed forward to promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon. Lubricate the tubing to prevent trauma or irritation to the rectal mucosa. The correct length of insertion of an adult patient is 7.6 to 10.2 cm (3 to 4 in). The maximum recommended height to hang enema container is 46 cm ( in). 13) A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply) a. Limit total daily fluid intake b. Decrease or avoid caffeine c. Take calcium supplements d. Avoid drinking alcohol e. Use the Crede maneuver - ANSb, d Rationale: Alcohol and caffeine is a bladder irritant and can worsen stress incontinence. Stress incontinence results from weak pelvic muscles and other structures, limiting fluids will not resolve the problem. 14) A client with an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is patent b. Reassure the client that it is not possible for them to urinate c. Recatheterize the bladder with a larger-gauge catheter d. Collect a urine specimen for analysis - ANSa Rationale: A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate. 15) A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following

actions should the nurse take? a. Discard the first voiding b. Keep the urine in a single container at room temperature c. Dispose the last voiding d. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container. - ANSa Rationale: Discard the first voiding of the 24-hour specimen and note the time. Voiding should be saved until the end of the collection period. 16) A nurse is reviewing factors that increase the risk of a urinary tract infection (UTIs). Which of the following factors should the nurse include? (Select all that apply) a. Frequent sexual intercourse b. Lowering of testosterone levels c. Wiping from front to back to clean the perineum d. Location of the urethra close to the anus e. Frequent catheterization - ANSa, d, e Rationale: Having frequent sexual intercourse increases the risk of UTIs in all clients. The close proximity of the urethra to the anus is a factor that increases the risk of an infection. Frequent catheterization and the use of indwelling catheters are risk factors for UTIs. 17) A nurse is preparing to initiate a bladder training program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply) a. Restrict the client's intake of fluids during the daytime b. Have the client record urination times c. Gradually increase the urination intervals d. Remind the client to hold urine until next

scheduled urination time e. Provide a sterile container for urine - ANSb, c, d Rationale: Asking the client to keep track of urination times, gradually increasing the intervals between urinations, and reminding the client to hold urine until the next scheduled time helps their progress toward the goal of 4-hr intervals between urination. 18) A female patient complains of abdominal discomfort. Watery stool has been leaking from her rectum. This could be a sign of a. Diarrhea b. Bowel incompetence c. Fecal impaction - ANSc Rationale: Fecal impaction can be serious. When constipation is not resolved, stool becomes hardened and unable to pass. Liquid stool may pass around the impaction. Patients may complain of feeling bloated; having the urge to push; nausea or vomiting; or not wanting to eat. The impaction may need to be manually removed. Patient education should include increasing liquids and fiber, as well as regular physical activity. 19) A client has a pressure ulcer on the sacrum. While assessing it, the nurse observes that it has partial thickness, loss of dermis, and a red-pink wound bed. Which stage will the nurse assign this pressure ulcer? a. Stage I b. Stage III c. Stage II d. Stage IV - ANSc Rationale: Stage I pressure ulcers have intact skin with a reddened area that may be firm and painful. Stage II pressure ulcers are indicated by partial thickness, loss of dermis, and a red-pink wound bed.

Stage III pressure ulcers have full-thickness skin loss and may contain slough, visible subcutaneous tissue, and tunneling. Stage IV pressure ulcers have full-thickness skin loss and exposed muscle, bone, or tendons. 2) The nurse receives a telephone call from the post anesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Assess the patency of the airway b. Check tubes or drains for patency c. Check the dressing to assess for bleeding d. Assess the vital signs to compare with preoperative measurements - ANSa Rationale: The first action of the nurse is to assess the patency of the airway and respiratory function. If the airway is not patent, the nurse must take immediate measures for the survival of the client. The nurse then takes vital signs followed by checking the dressing and the tubes or drains. The other nursing actions should be performed after a patent airway has been established. 20) A patient diagnosed with Crohn's disease has a new colostomy. When assessing the patient's stoma, which of these would alert the HCP that the stoma has retracted? a. Pinkish red and moist b. Narrowed and flattened c. Concave and bowl shaped d. Dry and reddish purple - ANSc Rationale: A colostomy is created when the bowel is pulled through an opening in the abdominal wall, creating a stoma through which intestinal

contents will pass. A healthy stoma will protrude about 2.5cm with an open lumen at the top. The stoma should appear pinkish red and moist. A dry, dusky, or reddish-purple stoma indicates ischemia. A narrowed, flattened, or constricted stoma indicates stenosis. A concave and bowl- shaped stoma has retracted. A retracted stoma can be difficult to care for. Complications include problems maintaining appliance placement, leading to leakage and sore skin. 21) Which meal best promotes healing for a patient recovering from a burn injury? a. Pork chop, fried potatoes, coffee b. Pasta marinara, garlic bread, ginger ale c. Chicken breast, strawberries, milk d. Peanut butter and jelly sandwich, banana, tea - ANSc Rationale: The meal with the best nutrition for wound-healing includes protein and vitamin-C. Foods that have low nutritional value, such as sugar or those with low or no calories, are not beneficial. 22) A nurse is caring for a client whose heel has a pressure ulcer covered with intact hard, dry, black tissue. Which is the appropriate dressing for this client? a. Apply a hydrocolloid dressing b. Cover with sterile gauze c. Do a wet-to-dry dressing change d. No dressing is necessary - ANSd Rationale: Current standard of care guidelines recommend that stable, intact (dry, adherent, intact without erythema) eschar on the heels should not be removed. Eschar works as a natural barrier or biological

dressing by protecting the wound bed from bacteria. Unless it is wet, draining, or loss, it should remain in place. Unless the nurse is a certified wound specialist, removal or debridement of eschar should be performed by a HCP. The other dressings are not indicated. 23) When a patient's nasogastric (NG) tube stops draining, what is the nurse's first action? a. Clamp for 1 hour b. Check tube placement c. Instill 50mL of water d. Retract 2 inches - ANSb Rationale: ALWAYS verify tube placement before taking other measures. NEVER put anything in a NG tube unless you know that its tip is in the stomach. Clamping has no effect on NG tube placement. Retracting without knowing where the tip is would be unsafe for the patient. 24) A client refers to the unit after abdominal surgery. While monitoring the client, the nurse observes a moderate amount of red blood on the dressing. The nurse will document this type of wound drainage as... a. Serosanguineous b. Sanguineous c. Purulent d. Serous - ANSb Rationale: Wound drainage is described by type, color, amount, and odor. Types of drainage are: 1. Serous: clear and thin; may be present in a healthy, healing wound. 2. Serosanguineous: containing blood; may also be present in a healthy, healing wound. 3. Sanguineous: primarily blood. 4. Purulent: thick, white, and pus-like; may be indicative of infection and should be

cultured. 25) When cleaning the perineal area around the site of an indwelling catheter, the nurse should... a. Vigorously wash the periurethral area b. Wipe the catheter away from the urinary meatus c. Scrub the tubing toward the urinary meatus d. Apply powder after giving perineal care - ANSb Rationale: The catheter should be wiped away from the meatus, to decrease the risk of introducing pathogens into the urinary tract. The perineum should be washed gently with soap and water. Powder can retain moisture, leading to an infection. 26) An unconscious trauma patient is admitted to the ICU. The HCP prescribes enteral feedings via the nasogastric (NG) tube. Before the nurse administers a formula feeding, which finding by the nurse requires IMMEDIATE action? a. The volume of residual formula is 90 mL b. Breath sounds are decreased in the right lower lobe. c. Urine output for the last 8 hours was 40 mL/hr d. Bowel sounds are hyperactive in all quadrants - ANSb Rationale: A major risk associated with enteral feedings is aspiration, resulting in atelectasis and pneumonia. The right lower lobe (RLL) is the most common site. Clients should be positioned at a minimum of 30 degrees of head elevation during feedings and up to two hours afterward. The nurse should verify tube placement before each feeding, or every four to eight hours if the client is receiving a

continuous feeding. Residual volumes of up to 100 mL are acceptable. Urine output of less than 30 mL/hr should be reported to the HCP. Decreased bowel sounds should be monitored but are not an immediate concern. 27) The tool that predicts the risk of developing a hospital- or facility- acquired pressure ulcer or injury is called the a. Braden Scale b. Likert Scale c. Misophonia Scale d. Apgar Scale - ANSa Rationale: The Braden Scale uses a score from less than or equal to 9 to as high as 23. The lower the number, the higher the risk for developing an acquired ulcer or injury. The Braden Scale should be used on admission, transfer, and receiving, and with any change in the client's condition. The Likert Scale is used on questionnaires. The Misophonia Scale is used for a disorder in which certain sounds trigger emotional or physiological responses. The Apgar Scale measures the health of a newborn. 28) The nurse is providing wound care for a client with a Stage III pressure ulcer. Which of the following signs indicates that the wound is healing? a. Skin is red and does not blanch when pressed b. The wound bed is getting smaller c. Appearance of the serum-filled blister d. Eschar covers the wound area - ANSb Rationale: The ulcer presents clinically as a deep crater with or without undetermined of adjacent tissue. Signs of healing include: the sore gets smaller; pinkish tissue starts forming along the

edges, moving to the center; some bleeding may be present, indicating good circulation to the area. Eschar is dead tissue; when it covers a pressure ulcer, the wound can't be staged, Skin that is red and doesn't blanch when pressed indicates a Stage I ulcer. Appearance of a serum- filled blister occurs in Stage II. 29) When caring for a client who has an order for strict I & O, which is the best way to obtain accurate measurements? a. Ask the client to write down how many cups of fluid he or she drinks b. Give the client a marked cup to measure urine output c. Clear and rest all IV pumps to zero on each shift d. Remind the client not to drink anything that's not on the meal tray - ANSc Rationale: The nurse or nursing delegate has sole responsibility for maintaining accurate I&O. Clearing and resetting IV pumps will provide this information. Not all clients are on restricted intake when I&O is being monitored, so they may ask for fluids other than those provided at meal times. Asking a client to record his or her own intake and output is not appropriate. 3) The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position? a. Left Sims' position b. Right Sims' position c. On the left side of the body, with the head of the bed elevated 45 degrees d. On the right side of the body, with the head of

the bed elevated 45 degrees. - ANSa Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in the Sims' position. 30) While providing preoperative education to a client, the nurse explains that the client will return from surgery with a sequential compression device (SCD). Which of the following statements by the nurse would be most correct? a. "You won't have to do any other exercises." b. "The SCD means you can stay on bed rest." c. "You will wear the SCD when ambulating." d. "The SCD imitates the action of walking." - ANSd Rationale: A Sequential Compression Device (SCD) is a method of DVT prevention that improves blood flow in the legs. SCDs are shaped like "sleeves" that wrap around the legs and inflate with air one at a time. This imitates walking and helps prevent blood clots. The SCD is worn while sitting or in bed; the device is removed for ambulating. Clients should still do foot exercises, including circles and flexing. Clients should be up and walking as soon as possible post-surgery, and continue to ambulate frequently. 31) One of the nurse's patients has a nasogastric (NG) tube for tube feedings and medications. Which nursing action is appropriate when caring for this patient? a. Check the area where the tape is applied qd b. Change the

tubing from the feeding q 48 hr c. Place the bed in the low Fowler's position for feedings d. Flush the NG tube q 4 hr with hot water - ANSa Rationale: The nurse should change the tape at the patient's nose every day and assess the skin for breakdown. Tubing and feeding items are replaced every 24 hours. The NG tube is flushed with warm water to avoid burning the patient or causing discomfort. The bed is placed in the high Fowler's position for tube feedings. 32) A client with a nasogastric (NG) tube complains that his nasal passage is irritated. Which action by the nurse is most appropriate? a. Apply a water-soluble lubricant to the nares b. Place the client in a lateral recumbent position c. Give the client an ice pack to hold on his nose d. Reposition the NG tube every 8 hours - ANSa Rationale: The nurse should apply a water-soluble lubricant to the irritated nare. Repositioning the NG tube will not eliminate the irritation. Placing the client in a different position or using an ice pack will not affect the client's discomfort within the nasal passage. 33) Before administering a soap suds enema, which position is appropriate for the client? a. Prone b. Supine c. Sims d. Lithotomy - ANSc Rationale: To receive an enema, the client should be in the Sims position. The client lies on his or her left side, with the right leg flexed forward. This position facilitates the flow of the enema solution into the rectum and colon.

Supine position is lying horizontally with the face and torso facing up. Prone position is lying horizontally with the torso down and the head turned to the side. Lithotomy position is lying on the back with hips and legs flexed 90 degrees. 34) Which type of ostomy puts a client at the MOST risk for skin breakdown? a. Sigmoid colostomy b. Ileal conduit c. Ileostomy d. Transverse colostomy - ANSc Rationale: An ostomy is an artificial excretory opening of the body. The ostomy type and leakage are major risk factors for skin complications. Ileostomy patients have been found to be at significantly greater risk of developing skin complications than colostomy patients. Ileostomy output, which is from the small intestine, is of a continuous, liquid nature. This output contains gastric and enzymatic agents that when present on the skin can denude the skin in a few hours. Because of the caustic nature of this stoma output, adequate peristomal skin protection must be delivered to prevent skin breakdown. With a transverse colostomy, the stool is of a somewhat mushy and soft nature. With a sigmoid colostomy, the output is formed with an intermittent output. An ileal conduit is a urinary diversion, with the ureters being brought out to the abdominal wall. 35) The bed of a patient who has an indwelling urinary catheter (Foley) is found wet with urine. After determining that the catheter is patent, the

nurse should: a. Tell the patient to use the bedpan when there is an urge to void b. Insert a larger-size catheter c. Provide perineal care whenever necessary d. Position a waterproof pad under the patient's buttocks - ANSb Rationale: Urine is leaking around the urinary retention catheter and a larger-size catheter is required; once ordered, it is within the role of the nurse to select the appropriate size catheter and perform the insertion. 36) The registered nurse who works on a medical/surgical unit cares for a patient with a feeding tube. What would cause the nurse to suspect that the feeding tube's placement is incorrect? a. The patient coughs frequently b. The patient develops a fever c. The pH of the aspirate is 3 d. The pH of the aspirate is 7 - ANSd Rationale: A pH of 7 indicates that the aspirate we have drawn comes from the lungs rather than the stomach. Normal stomach pH is 1-4. 37) A nurse educator is reviewing the wound healing process with a group of nurses. The nurse educator should include in the information which of the following alterations for wound healing by secondary intention? (Select all that apply.) a. Stage 3 pressure injury b. Sutured surgical incision c. Casted bone fracture d. Laceration sealed with adhesive e. Open burn area - ANSa, e Rationale: Open burn areas and pressure ulcers heal by secondary intention, which is the process for wounds that have tissue

loss and widely separated edges. Sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, which is the process for wounds that have little or no tissue loss and well- approximated edges. Unless the bone edges have pierced the skin, a casted bone fracture is an injury to underlying structures and does not require healing of the skin. 38) A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply.) a. Cover the area with saline-soaked sterile dressings b. Apply an abdominal binder snugly around the abdomen c. Use sterile gauze to apply gentle pressure to the exposed tissues d. Position the client supine with the hips and knees bent e. Offer the client a warm beverage (herbal tea) - ANSa, d Rationale: Cover the wound with the sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. The supine position minimizes pressure on the abdominal area. 39) A nurse is caring for a client who is at risk for developing pressure injury, Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? (Select all that

apply.) a. Keep the head of the bed elevated 30 degrees b. Massage the client's bony prominences frequently c. Apply cornstarch liberally to the skin after bathing d. Have the client sit on the gel cushion when in a chair e. Reposition the client at least every 3 hr while in bed - ANSa, d Rationale: Slightly elevate the head of the client's bed to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. Have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas. Repositioning the client at least every 2 hours. Frequent position changes are important for preventing skin breakdown, but every 3 hours is not frequent enough. 4) The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion? a. Right side b. Low Fowler's c. High fowler's d. Supine with the head flat - ANSc Rationale: During insertion of a nasogastric tube, the client is placed in a sitting or high Fowler's position to facilitate insertions of the tube and reduce the risk of pulmonary aspiration if the client should vomit. The right side, and low Fowler's and supine positions place the client at risk for aspiration; in addition, these positions do not facilitate insertion of the tube. 5) The nurse is preparing to administer medication using a client's nasogastric tube. What actions should the nurse take before administering the

medication? Select all that apply. a. Check the residual volume b. Aspirate the stomach contents c. Turn off the suction to the nasogastric tube d. Remove the tube and place it in the other nostril e. Test the stomach contents for a pH indicating acidity - ANSa, b, c, e Rationale: By aspirating stomach contents, the residual volume can be determined, and the pH checked. A pH less than 3.5 verifies gastric placement. The suction should be turned off before the tubing is disconnected to check for residual volume; in addition, suction should remain off for 30 to 60 minutes following medication administration to allow for medication absorption. There is no need to remove the tube and place it in the other nostril in order to administer a feeding; in fact, this is an invasive procedure and is unnecessary. 6) The nurse is preparing to administer medication through a nasogastric tube that is connected to suction. To administer the medication, the nurse should take which action? a. Position the client supine to assist in medication absorption b. Aspirate the nasogastric tube after medication administration to maintain patency. c. Clamp the nasogastric tube for 30 to 60 minutes following administration of the medication d. Change the suction setting to low intermittent suction for 30 minutes after medication administration - ANSc Rationale: If the client has a nasogastric tube connected to suction,

the nurse should wait 30 to 60 minutes before reconnecting the tube to suction apparatus to allow adequate time for medication absorption. The client should not be placed in the supine position because of the risk for aspiration. Aspirating the nasogastric tube will remove the medication just administered. Low intermittent suction also will remove the medication just administered. 7) The nurse is assessing for correct placement of a nasogastric tube. The nurse aspirates the stomach contents, checks the gastric pH, and notes a pH of 7.35, Based on this information, which action should the nurse take at this time? a. Retest the pH using another strip b. Document that the nasogastric tube is in the correct place c. Check for placement by auscultating for air injected into the tube d. Call the health care provider to request a prescription for a chest radiograph (xray) - ANSd Rationale: If the nasogastric tube is in the stomach, the pH of the contents will be acidic. Gastric aspirates have acidic pH values and should be 3.5 or lower. A pH of 7.35 indicates a neutral pH, which may indicate that the tube is no longer in the stomach. Based on this information, the nurse should call the HCP to request a chest xray to determine if placement is accurate. Retesting the pH using another test strip is unnecessary and checking for placement by auscultating for air injected into the tube is not a definitive method of

checking for tube placement. The nurse should not document that the tube is in the correct place because the data indicates this may not be the case. 8) The registered nurse is preparing to insert a nasogastric tube in an adult client. To determine the accurate measurement of the length of the tube to be inserted, the nurse should take which action? a. Mark the tube at 10 inches (25.5 cm) b. Mark the tube a 32 inches (81 cm) c. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the xiphoid process d. Place the tube at the tip of the nose and measure by extending the tube to the earlobe and then down to the top of the sternum - ANSc Rationale: Measuring the length of a nasogastric tube needed is done by placing the tube at the tip of the client's nose and extending the tube to the earlobe and then down to the xiphoid process. The average length for an adult is about 22 to 26 inches (56 to 66 cm). The remaining options identify incorrect procedures for measuring the length of the tube. 9) The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)? a. Dark red drainage b. Dark brown drainage c. Green-tinged drainage d. Light yellowish-brown drainage - ANSa Rationale: For the first 12 hours

after gastric surgery, the nasogastric tube drainage may be dark brown to dark red. Later, the drainage should change to a light yellowish-brown color. The presence of bile may cause a green-tinge. The HCP should be notified if dark red drainage, a sign of hemorrhage, is noted 24 hours postoperatively. A 56 year-old patient, who has recently become postmenopausal, made an appointment with her health care provider for symptoms of a UTI. The patient has had three previously diagnosed UTIs in the past 4 months. She asks the nurse if this is a normal occurrence with postmenopausal women. What is the best response from the nurse? a. "Yes, and this is why I'm not looking forward to going through menopause." b. Yes, because as women go through menopause, the lining of the urethra becomes more susceptible to infections." c. "No, but why don't you ask your health care provider for some antibiotics to keep on hand?" d. "Yes, and this must be frustrating because as we become older our body starts to cause us more problems." - ANSb A client who had surgery this morning has a distended bladder and is unable to void. Which nursing interventions are most appropriate initially? Select all that apply. 1. Run warm water over the perineum 2. Have the client listen to the sound of running water 3. Obtain a prescription for an indwelling urinary catheter 4. Position the

client on a bedpan with the head the bed elevated 5. Perform a bladder ultrasonography to evaluate the amount of urine left in the bladder - ANS1, 2, 4, 5 Rationale: Before performing any interventions, the nurse should use a bladder ultrasonography to obtain data about the amount of urine in the client's bladder. The nurse should first use conservative methods such as maintaining a functional position with the head of the bed elevated, running warm water over the perineum, and having the client listen to the sound of running water. If these interventions are unsuccessful, the nurse should obtain a prescription for a straight catheterization. The use of an indwelling catheter places the client at risk for infection. A male patient has been admitted with a fever and malaise. The HCP had ordered a clean catch midstream specimen for urinalysis on this patient. To collect the urine specimen, the nurse should instruct the patient to do which of the following? a. Ask the patient to void into a cup or urine collection container b. Cleanse his penis, begin his stream, and then void into a sterile cup c. Return to bed to obtain the specimen using a straight catheter insertion d. Use sterile gloves to cleanse his penis and collect the specimen in a sterile cup. - ANSb A nurse has delegated the administration of a tap water enema to a nursing assistive personnel (NAP). The NAP demonstrates understanding of the procedure when she

states which of the following? (Select all that apply) a. "I will lower the enema when the patient complains of cramping" b. :I will speed up the enema administration when the patient complains of cramping" c. "I will withdraw the tube when the patient complains of cramping" d. "I will clamp the tubing when the patient complains of cramping" e. "I will fill the bag with hot water because it will cool while I am administering the enema" f. "I will have the patient sit on the toilet while I am administering the enema" - ANSa, d A nurse suspects that a patient may be experiencing urinary retention. What should the nurse expect to find on assessment? a. Spasms and difficulty urinating b. Pain in the umbilical region c. Large amounts of voided cloudy urine d. Small amounts of urine voided 2 to 3 times her hour - ANSd A patient is undergoing abdominal surgeries, which will most likely result in an ostomy. The patient asks the nurse, "what will the stool from my ostomy look like?" What is the best answer? a. "The consistency of your stools will be very soft" b. "The consistency of your stools will depend on the location of the stoma (ostomy)" c. "Your stools won't change from what they currently are" d. "The consistency of your stools will be liquid" - ANSb A patient needs to have a foley catheter inserted. Place the following steps into the correct order for this procedure. 1. Apply sterile gloves 2. Open

the catheterization kit 3. Wash the perineal area with soap and water 4. Position the patient 5. Drape the perineum 6. Clean the urethra - ANS4, 3, 2. 5, 1, 6 A patient states that she is unable to get her transparent dressing to stay in place. What instruction should the nurse provide the patient? a. "If you are having difficulty with your dressing changes, we can see if the doctor will give you a referral to a home care agency." b. "Make sure that you have a margin of 1 to 1.5 inches around the wound, and that the skin is thoroughly dry before applying the dressing." c. "This type of dressing requires frequent changing because they do not stay in place." d. "You probably are applying it incorrectly , or perhaps you are just too anxious about having to perform the dressing change." e. "There are many options on the market. Why don't you use a nonadhesive- backed transparent dressing instead?" - ANSb Rationale: If the transparent dressing does not stay in place, the size of the dressing should be evaluated for adequate (1 to 1.5 inches) margin, and the skin should be dried thoroughly before reapplication. The patient requires further instruction, not necessarily a referral, regarding interventions to aid in dressing adherence. The dressing coming off is an unexpected outcome. Blaming the patient is non- therapeutic. A patient with a Foley catheter needs a urine sample for culture and sensitivity. What is the

most appropriate action for the nurse to take? a. Insert a sterile blunt cannula in the catheter port to withdraw urine b. Open the drainage bag and withdraw urine c. Disconnect the drainage tube from the catheter d. Withdraw urine from the close system drainage bag - ANSa After receiving an intramuscular (IM) injection in the deltoid, a patient states, "My arm really hurts. It's burning and tingling where I got my injection." What should the nurse do next? (Select all that apply) 1. Assess the injection site 2. Administer an oral medication for pain 3. Notify the patient's health care provider of assessment findings 4. Document assessment findings and related interventions in the patient's medical record 5. This is a normal finding, so nothing needs to be done 6. Apply ice to the site for relief of burning pain - ANS1, 3, 4 Rationale: Assessing the injection site may reveal a sire reaction or induration from the injection. The health care provider needs to be notified in case there is an adverse effect from the injection. The nurse must always document adverse effects so that the site and patient can be monitored. An 80 year-old woman with a history of diabetes and arthritis has made an appointment with her health care provider for complaints of urinary incontinence (UI). The patient states that she has recently become incontinent of urine and thinks it is because of her age. What is the best