exam 4

1. A 55-year-old male patient post-myocardial infarction (MI) asks the nurse whether he will be healthy enough for sexual activity after discharge from the hospital. The patient has been prescribed anti-hypertensives and beta-blockers. During health teach

ANS: A
During these three phases, heart rate, blood pressure, and respirations increase steadily, increasing stress to the heart muscle. This would be the period of greatest concern for a patient who has recently experienced an MI. The plateau and orgasmi

2. In order to fully assess the patient and plan appropriate care including health teaching regarding sexuality the nurse should realize that which patient is most at risk for sexual abuse?
a.
A recently divorced 50-year-old woman
b.
A Hispanic teenage gi

ANS: D
As more of these individuals move into mainstream society, it is important that sexual health is promoted, including teaching regarding sexual norms. Otherwise these individuals are likely victims of unhealthy sexual practices or sexual abuse. In t

3. A 37-year-old heterosexual African-American man has come for his annual health screening. Which test must the nurse ensure is ordered for this patient?
a.
Human papilloma virus (HPV)
b.
Prostate-specific antigen (PSA)
c.
HIV
d.
Venereal disease researc

ANS: B
PSA testing is recommended annually for men at increased risk for prostate cancer. This includes men with a family history or those of African-American descent. HPV testing would likely be ordered for patients with genital warts. This might not be

4. The school nurse is developing a curriculum for a junior human sexuality class. In order to provide the most up-to-date information, the nurse should be aware that which is the single most effective primary prevention strategy for preventing sexually t

ANS: C
The single most effective (100%) way to prevent sexually transmitted infections is abstinence. When used correctly, the male condom is an effective method for preventing sexually transmitted infections as well as being a very highly effective contr

5. The nurse is caring for a 44-year-old married woman who is complaining of painful intercourse and incontinence due to prolapse of reproductive organs. Clinical evaluation reveals that the patient has a cystocele. Which treatment option is most appropri

ANS: C
Depending on the cause, a cystocele can be readily corrected by surgery. Pelvic muscle floor training (Kegel exercises) will most definitely help with symptoms of urinary incontinence. This alone is not adequate treatment for this patient. Vaginal

6. When assessing high-risk behaviors, which question specifically identifies a blood-related risk for a sexually transmitted infection?
a.
"Have you ever received donor semen, eggs, or transplanted tissue?"
b.
"Have you ever exchanged sex for drugs, mone

ANS: A
Receipt of any donated organ, tissue, semen, or eggs is considered a blood-related risk. Other blood-related risks include blood transfusion, sex with a person with hemophilia, or sharing equipment for tattoos and body piercing. The exchange of sex

1. Which statements related to sexual dysfunction are correct? (Select all that apply.)
a.
Biological factors play a more significant role than psychologic factors.
b.
Sexual dysfunction is more prevalent among men than women.
c.
The best predictor of sex

ANS: C, D
The best predictor of sexual health is emotional well-being rather than the impairment of the physical aspects of sexual arousal and function. Nurses must remain cognizant that sexual dysfunction, regardless of the cause, is likely to result in

1. A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual partners. Which response by the nurse will be most effective?
a. "Sexually transmitted infections and unwanted pregnancy are a real risk. Let's discuss

ANS: A
Some adolescents participate in risky behaviors. The nurse should acknowledge this feeling to the patient and offer education and alternatives, while giving the patient the autonomy to make his or her own decisions. Adolescents who engage in sexual

2. A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse's religious and ethical values are strongly opposed. How should the nurse best handle the situation?
a. Attempt to educate the patient about the consequences

ANS: B
The nurse must be aware of personal beliefs and values and is not required to participate in counseling or procedures that compromise those values. However, the patient is entitled to nonjudgmental care and should be referred to someone who can cre

3. Which patient is most in need of a nurse's referral to adoption services?
a. A woman considering abortion for an unwanted pregnancy
b. An infertile couple religiously opposed to artificial insemination
c. A woman who suffered miscarriage during her fir

ANS: B
Adoption is an option for someone with infertility, especially if infertility treatments are unavailable owing to religious or financial constraints. A patient who wishes to have an elective abortion may be educated about all the possibilities, but

4. The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV .
Which response by the nurse is best?
a. "You should have your blood drawn today to see if you were infected."
b. "If you have the virus, you will have flu-l

ANS: C
Highly active retroviral therapy increases the survival time of a person with HIV or AIDS. HIV antibodies will not show up in blood work for 6 weeks to 3 months. The infection stage of HIV lasts for about a month after the virus is contracted; duri

5. An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. Which response by the nurse will help establish a trusting relationship?
a. "Don't worry. It's just a phase you will grow out

ANS: C
Adolescents have questions about sexuality. The patient will feel most comfortable discussing his sexual concerns further if the nurse establishes that it is normal to ask questions about sexuality. The nurse can then discuss in greater detail. Alt

6. A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated attempts at fertility treatment. The patient tells the nurse, "I feel happier, but my sex driveis gone." Which nursing diagnosis has the highe

ANS: A
Antidepressants have adverse effects on sexual desire and response. The nurse should be sure to educate the patient on the potential for these side effects and how to correct for them, for example, using lubricant to ease discomfort. The patient ha

7. A nurse is using the PLISSIT model when caring for a patient with dyspareunia from diminished vaginal secretions. The nurse suggests using water-soluble lubricants. Which component of PLISSIT is the nurse using?
a. P
b. LI
c. SS
d. IT

ANS: C
The nurse is using the specific suggestions (SS). The PLISSIT model is as follows:
Permission to discuss sexuality issuesLimited Information related to sexual health problems being experienced Specific Suggestions�only when the nurse is clear about

8. A patient who has had several sexual partners in the past month expresses a desire to use a contraceptive. Which contraceptive method should the nurse recommend?
a. Condom
b. Diaphragm
c. Spermicide
d. Oral contraceptive

ANS: A
Condoms are both a contraceptive and a barrier against STIs and HIV; proper use will greatly reduce the risk. Spermicides, diaphragms, and oral contraceptives all protect against pregnancy; however, they are not a barrier and do not prevent bodily

9. A woman who has been in a monogamous relationship for the past 6 months presents to clinic with herpes on her labia. The patient is distraught because her partner must have cheated on her.Which response by the nurse is most effective in establishing an

ANS: B
If open communication is to be established with the patient, the patient must know that she can trust health care team members. By telling the patient that all encounters are confidential, the nurse establishes trust. Sharing a story brings the foc

10. A nurse is preparing a community class about sexually transmitted infections. Which primary group will the nurse focus on for this class?
a. Bisexual women
b. Men who have sex with men
c. Youths between the ages of 24 and 27
d. Pregnant women and thei

ANS: B
About 20 million people in the United States are diagnosed with an STI each year, with the highest incidence occurring in men who have sex with men, bisexual men, and youths between the ages of 15 and 24. While bisexual women, youths between the ag

11. The nurse is leading a seminar about menopause and age-related changes. Which response from a group member indicates the nurse needs to follow up?
a. "Hormones of sexual regulation decrease with aging."
b. "Orgasms are no longer achievable after menop

ANS: B
Believing that orgasms are no long achievable requires follow-up to correct this misconception. Orgasms are achievable at any age; however, it may take longer with aging. All other statements indicate that the patient does have an understanding of

12. A patient who had a colostomy placed 1 month ago is feeling depressed and does not want to participate in sexual activities anymore. The patient is afraid that the partner does not want sex. The patient is afraid the ostomy is physically unattractive.

ANS: D
The nurse should first address the patient's need to be comfortable with his or her own body image; once the patient's issues related to body image are resolved, intimacy may follow. Reassuring the patient that others manage to have sexual intercou

13. A mother brings her 12-year-old daughter into a clinic and inquires about getting a human papillomavirus (HPV) vaccine that day. Which information will the nurse share with the mother and daughter about the HPV vaccine?
a. Protects against human immun

ANS: B
The HPV vaccine is effective against the four most common types of HPVs that can cause cervical cancer. It is not effective against HIV, chlamydia, or pregnancy.
DIF:Understand (comprehension)REF:719-720 | 728
OBJ: Discuss the nurse's role in maint

14. A parent asks about the human papillomavirus (HPV) vaccine. Which information will the nurse include in the teaching session?
a. It is recommended for girls 6 to 9 years old.
b. It is recommended for females ages 11 to 26.
c. It is recommended that bo

ANS: B
The vaccine is safe for girls as young as 9 years old and is recommended for females ages 11 to 26 if they have not already completed the three required injections. Booster doses currently are not recommended. The vaccine is most effective if admin

15. A nursing student is providing education to a group of older adults who are in an independent living retirement village. Which statement made by the nursing student requires the nurse to intervene?
a. "Avoiding alcohol use will enhance your sexual fun

ANS: C
Research indicates many older adults are more sexuality active than previously thought and engage in high-risk sexual encounters, resulting in a steady increase HIV and STI rates over the past 12 years. Therefore, the nurse needs to intervene when

16. A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require the nurse to follow up?
a. "I have lost 12 pounds on this diet."
b. "I use the diaphragm to prevent pregnancy."
c. "I use a contraceptive cream with

ANS: A
The woman needs to be refitted after a significant change in weight (10-pound gain or loss) or pregnancy. The diaphragm is a round, rubber dome that has a flexible spring around the edge. It is used with a contraceptive cream or jelly and is insert

17. A nurse is conducting a sexual assessment. Which question is appropriate for the nurse to ask?
a. Have you noticed any changes in the way you feel about yourself?
b. What is your favorite sex position with men and with women?
c. Do you think your part

ANS: A
Asking about any changes in the way you feel about yourself is an appropriate question to ask during a sexual assessment. Asking about favorite sex position with men and/or women is inappropriate and invasive. The assessment needs to focus on the p

18. A 15-year-old patient is concerned because her mother wants her to receive the human papillomavirus (HPV) vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic?
a. Ask the patient what concerns she may

ANS: A
The nurse should encourage health promotion behaviors but first must consider the autonomy of the patient and assess the patient for more data. The nurse should value the input of the patient in making a decision and assess what the patient is thin

19. A nurse is reviewing a patient's history. Which priority finding will alert the nurse to assess the patient for possible sexual dysfunction?
a. Takes vacations out of the country
b. Takes antianxiety medication
c. Takes exercise classes
d. Takes after

ANS: B
Medications that can affect sexual functioning include antihypertensive, antipsychotics, antidepressants, and antianxiety. Taking vacations out of the country, exercise classes, and afternoon naps are not as priority for sexual functioning as medic

20. A nurse is assessing a child for sexual abuse. Which assessment findings will the nurse expect?
a. Physical aggression and sleep disturbances
b. Many peers and no drug usage
c. Panic attacks and anorexia
d. Anxiety and depression

ANS: A
Behavioral signs of sexual abuse in a child include physical aggression, sleep disturbance, poor peer relationships, and substance abuse. Panic attacks, anorexia, anxiety, and depression are behavioral signs for adults.

21. The nurse is teaching a patient how to use a condom. Which instructions will the nurse provide?
a. Store in a warm lit space.
b. Use massage oils for lubrication.
c. Rinse and reuse the condom if needed.
d. Hold onto the condom when pulling out.

ANS: D
Teach patients to pull out right after ejaculating and to hold onto the condom when pulling out. Store condoms in a cool, dry place away from sunlight. Instruct patient to never reuse a condom or use a damaged condom. Instruct patient to only use w

1. An older couple expresses concern because they are easily fatigued during sexual intercourse and cannot reach climax. Which strategies to increase sexual stamina will the nurse offer? (Select all that apply.)
a. Plan sexual activity around a time when

ANS: A, E, F
Alcohol, tobacco, and certain medications (such as narcotics for pain) may cause drowsiness and fatigue and negatively affect sexual stamina. Eating well-balanced meals can help to increase energy levels. Planning sexual activity when the cou

1. A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an

ANS: D
This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation.

2. The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements?
a.
"This will help us to identify your bab

ANS: D
Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby's response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone

3. An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response?
a.
"Your wife should increase the spices in your food, as the pneumonia change

ANS: D
Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of th

4. An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the

ANS: C
Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one's own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. Th

5. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase?
a.
Place the television to the left or right of patient'

ANS: C
Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degenera

6. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action?
a.
Notify the physician.
b.
Document the finding in the records.
c.
Recheck the reflex after several hours.
d.
Monitor

ANS: A
The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

7. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?
a.
"I will take my child to the audiologist because he doesn't seem to hear me except when

ANS: B
Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing

8. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the p

ANS: B
The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been

1. A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" How will the nurse interpret the finding when the child said that it was sharp?
a. The child's sensation is i

ANS: C
When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person's experiences. Sensation is a general term that refers to awarenes

3. A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
a. The patient frequently cleans out eyes with saline washes.
b. The patient applies different spices during mealtime to food.
c.

ANS: C
Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indicates that the patient alters behavior to accommodate for the sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the eye an

4. The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit?
a. Xerostomia
b. Dysequilibrium
c. Diabetic retinopathy
. Peripheral neuropathy

ANS: A
Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat and can lead to nutritional problems. The other options do not address taste- or nutrition-related concerns. Disequilibrium is balance. Diabetic retinopa

5. A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?
a. Impaired night vision
b. Difficulty hearing low pitch
c. Heightened sense of smell
d. Increased taste discrimination

ANS: A
Night vision becomes impaired as physiological changes in the aging eye occur. Older adults lose the ability to distinguish high-pitched noises and consonants. Senses of smell and taste are also decreased with aging.

6. A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse "Should I stop driving?" Which response by the nurse is most therapeutic?
a. "Yes, you shou

ANS: C
Part of the normal aging process is reduced ability to see colors. The nurse should teach the patient new ways to adapt to this deficit. This patient's accident was not due to impaired cognitive function or reflexes. Glasses will not assist the pat

7. A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse i

ANS: A
Because a stroke often causes partial or complete paralysis of one side of a patient's body, the patient needs special assistive devices. The nurse should include interventions that help the patient adapt to this deficit while maintaining independe

8. A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?
a. Risk for falls
b. Self-care deficit
c. Social isolation
d. Impaired physical mobility

ANS: C
In focusing on the psychological aspect of care, the nurse is most concerned about social isolation for a patient who may have difficulty communicating owing to visual and hearing impairment. Self-care deficit, impaired physical mobility, and fall

9. During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?
a. Neurological deficit
b. Visual deficit
c. Hearing deficit
d. Balance deficit

ANS: D
Vertigo is a result of vestibular dysfunction and often is precipitated by a change in head position. Neurological deficits include peripheral neuropathy and stroke. Visual deficits include presbyopia, cataracts, glaucoma, and macular degeneration.

10. A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected?
a. Perceptual
b.

ANS: A
Alterations in spatial orientation and in visual/motor coordination are signs of perceptual dysfunction. Cognitive function is the ability to think and the capacity to learn; the patient is not disoriented or unable to learn. Affective problems inc

11. Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability?
a. "Have you stopped reading books or switched to books on audiotape?"
b. "What do you do to protect yourself from

ANS: C
To best understand how vision is affecting self-care ability, the nurse wants to target questions to encompass what self-care tasks the patient has difficulty doing, such as preparing meals and writing checks. Switching to books on audiotape gives

12. A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?
a. Administer a Mini-Mental State Examination (MMSE).
b. Ask the patient to state name, location, and what month it is.
c. Ask the patient's family if the patie

ANS: A
The MMSE is a formal diagnostic tool that is used to assess a patient's level of cognitivefunctioning. The Mini-Mental State Examination (MMSE) is a tool you can use to measure disorientation, change in problem-solving abilities, and altered concep

13. The nurse is using the Snellen chart. Which patient is the nurse assessing?
a. A patient who frequently reports the incorrect time from the clock across the room.
b. A patient who is having difficulty remembering how to perform familiar tasks.
c. A pa

ANS: A
The Snellen chart is used to assess vision. Difficulty remembering how to perform familiar tasks indicates the need to further assess mental and cognitive status. Turning the television up louder indicates the need for a hearing assessment. For a p

14. A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient?
a. "Rinse your mouth several

ANS: A
Good oral hygiene keeps the taste buds well hydrated. Having an unpleasant taste in the mouth discourages the patient from eating. Well-seasoned, differently textured food eaten separately heightens taste perception. Avoid blending foods together b

15. The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit?
a. Body image disturbance
b. Social isolation
c. Risk for falls

ANS: C
A visual disturbance poses great risk for injury due to falling from impaired depth perception and inability to see obstacles. Body image disturbance, social isolation, and fear are all valid nursing diagnoses that apply to a patient with vision de

16. The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?
a. Expressive
b. Receptive
c. Global
d. Motor

ANS: B
Sensory or receptive aphasia is the inability to understand written or spoken language. A patient is able to express words but is unable to understand questions or comments of others. Expressive aphasia, a motor type of aphasia, is the inability to

17. The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?
a. Speaking with hands, face, and ex

ANS: A
Use visible expressions. Speak with your hands, your face, and your eyes. Do not shout. Speaking in loud tones can distort a patient's ability to hear; the nurse should speak in normal low tones. If the
patient does not understand the first time, t

18. The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the pa

ANS: B
If a patient with tactile deficits also has a visual impairment, it is important to be sure that water faucets are clearly marked "hot" and "cold," or use color codes (i.e., red for hot and blue for cold). Discourage the use of heating pads in this

19. A nurse is working to prevent blindness. Which preventive action is a priority?
a. Screen young adults early for visual impairments.
b. Include rubella and syphilis screening in the preconception care plan.
c. Instruct parents to report reduced eye co

ANS: B
Actions to prevent blindness must occur before vision impairment takes place. Screening for diseases such as rubella, syphilis, chlamydia, and gonorrhea that affect development of vision in the fetus is a preventative measure. Vision testing after

20. The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse

ANS: D
Control of excessive stimuli becomes an important part of a patient's care; earplugs provide relief. Quiet time means dimming the lights throughout the unit, closing the shades, and shutting the doors. Allow patients to shut their room door to decr

21. The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?
a. Patient will carry a pen and a pad of paper around for communication.
b. Patient will recover full use o

ANS: D
Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. To adapt to expressive aphasia, the nurse and the patient need to work on ways to communicate nonverbally through mean

22. The nurse is caring for a group of patients and is monitoring for sensory deprivation.Which patient will the nurse monitor most closely?
a. A patient in the ICU under constant monitoring following a myocardial infarction
b. A patient on the unit with

ANS: B
A group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis. Sensory deprivation occurs when a person has decreased stimulation and limited sensory input. A patient in isolation (

23. A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?
a. Offer the patient a back rub.
b. Hang a "Do not disturb" sign on patient's door.
c. Ask the patient "Would you like a new

ANS: A
Comfort measures such as washing the face and hands and providing back rubs improve the quality of stimulation and lessen the chance of sensory deprivation. The patient with sensory deprivation needs meaningful stimuli, and therapeutic massage help

24. The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a "Do not disturb" sign on the

ANS: C
The nurse acts as an advocate for the patient (who is experiencing sensory overload and would benefit from a quiet environment) by firmly and politely asking the surgeon to leave regardless of position in the hospital. A creative solution to decrea

25. The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion?
a. Keep a day-by-da

ANS: A
Keeping a calendar in the patient's room helps to orient the patient to the dates. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health c

26. A nurse is establishing a relationship with the patient who is severely visually impaired and is teaching the patient how to contact the nurse for assistance. Which action will the nurse take?
a. Place a raised Braille sticker on the call button.
b. E

ANS: A
The nurse should devise a plan of care that is accommodating of the patient's visual deficit. Placing a sticker on the call light allows the patient to page the nurse for assistance as needed. Using family members is not the best option. Making hou

27. The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority?
a. Hearing
b. Vision
c. Smell
d. Taste

ANS: A
Some antibiotics (e.g., streptomycin, gentamicin, and tobramycin) are ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Smell and taste are not as affected.

29. A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?
a. Dressing the left side first
b. Dressing the right side first
c. Dre

ANS: A
Dressing the left side first will be praised by the nurse. If a patient has partial paralysis and reduced sensation, the patient dresses the affected side first; in this case, the left. A stroke on the right hemisphere affects the left side of the

1. A home care nurse is inspecting a patient's house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.)
a. Stairway faintly lit
b. Bathtub with grab bars
c. Scatter rugs in the kitchen
d. Absenc

ANS: A, C, D
Assess the patient's home for common hazards, including the following: (1) loose area rugs and runner placed over carpeting, (2) poor lighting in stairways, and (3) absence of smoke alarms. Because of reduced depth perception, patients can tr

1. The home care nurse is assessing an older patient diagnosed with mild cognitive impairment (MCI) in the home setting. Which information is of concern?
a.
The patient's son uses a marked pillbox to set up the patient's medications weekly.
b.
The patient

ANS: B
A 10-pound weight loss in 1 month could indicate cancer or may be an indication of further progression of memory loss. Depression is also another common cause of weight loss. The use of a marked pillbox and planning by the family for 24-hour care a

2. The nurse is assisting a 79-year-old patient with information about diet and weight loss. The patient has a body mass index (BMI) of 31. How should the nurse instruct this patient?
a.
"Your weight is within normal limits. Continue maintaining with curr

ANS: D
This patient is at an increased risk for sarcopenia and should be instructed to increase activity that includes strength training to prevent muscle loss. Diet is not indicated. A BMI of 31 is considered obese; however, this patient does not qualify

3. The nurse is completing a nutritional assessment on a patient with hypertension. What foods would be recommended for this patient?
a.
Regular diet
b.
Low sodium diet
c.
Pureed diet
d.
Low sugar diet

ANS: B
A low sodium diet will prevent water retention which could increase blood pressure. Patients with hypertension would not be on a regular diet due to sodium content. A pureed diet is indicated for stroke patients who may have impaired swallowing. A

4. During a nutritional assessment, the nurse calculates that a female patient's BMI is 27. The nurse would advise the patient to follow which of these recommendations?
a.
This measurement indicates that the patient is overweight and should follow a plan

ANS: A
A BMI of 25 to 29.9 is in the overweight range. A BMI of <18.5 is in the underweight range. A BMI of 30 to 34.9 is obesity class I, a BMI of 35 to 39.9 is obesity class II, and a BMI of >40 is obesity class III (morbid obesity). A BMI of 19 to 24 i

5. During an interview, the nurse is discussing dietary habits with a patient. Which tool would be the best choice to use as a quick screening tool to assess dietary intake?
a.
Food diary
b.
Calorie count
c.
Comprehensive diet history
d.
24-hour recall

ANS: D
A 24-hour recall is useful as a quick screening tool to assess dietary intake. A food diary provides detailed information, but it is not convenient and requires a follow-up visit. A calorie count requires several days to collect data and requires a

6. During a physical examination, the nurse notes that the patient's skin is dry and flaking, with patches of eczema. Which nutritional deficiency might be present?
a.
Vitamin C
b.
Vitamin B
c.
Essential fatty acid
d.
Protein

NS: C
Dry and scaly skin is a manifestation of essential fatty acid deficiency. Vitamin C deficiency causes bleeding gums, arthralgia, and petechiae. Vitamin B deficiency is too large a category to consider. Specific categories of vitamin B deficiency hav

7. During a physical examination, the nurse notes that the patient's skin is dry and flaking. What additional data would the nurse expect to find to confirm the suspicion of a nutritional deficiency?
a.
Hair loss and hair that is easily removed from the s

ANS: A
Hair loss (alopecia) and hair that is easily removed from the scalp (easy pluckability), like dry, flaking skin, is caused by essential fatty acid deficiency. Inflammation of the tongue (glossitis) and fissured tongue are manifestations of a niacin

1. An African American is at an increased risk for which of the following? (Select all that apply.)
a.
Vitamin D deficiency
b.
Type 1 diabetes
c.
Celiac disease
d.
Type 2 diabetes
e.
Hypertension
f.
Metabolic syndrome

ANS: A, D, E, F
Type 1 diabetes and celiac disease are more common in Northern European heritage.

1. A patient who was diagnosed with senile dementia has become incontinent of urine. The patient's daughter asks the nurse why this is happening. What is the nurse's best response?
a.
"The patient is angry about the dementia diagnosis."
b.
"The patient is

ANS: B
Anger, wanting to leave the hospital, and forgetting where the bathroom is really have no bearing on the urinary incontinence. The patient is incontinent due to the mental ability to voluntarily control the sphincter. This is happening because of t

2. The nurse is caring for a patient who has suffered a spinal cord injury and is concerned about the patient's elimination status. What is the nurse's best action?
a.
Speak with the patient's family about food choices.
b.
Establish a bowel and bladder pr

ANS: B
Establishing a bowel and bladder program for the patient is a priority to be sure that adequate elimination is happening for the patient with a spinal cord injury. Speaking with the family to determine food choices is not the primary concern. Speak

3. The process of digestion is important for every living organism for the purpose of nourishment. Where does most digestion take place in the body?
a.
Large intestine
b.
Stomach
c.
Small intestine
d.
Pancreas

ANS: C
Most digestion takes place in the small intestine. The main function of the large intestine is water absorption. The pancreas contains digestive enzymes; the stomach secrets hydrochloric acid to assist with food breakdown.

4. The nurse is listening for bowel sounds in a postoperative patient. The bowel sounds are slow, as they are heard only every 3 to 4 minutes. The patient asks the nurse why this is happening. What is the nurse's best response?
a.
"Anesthesia during surge

ANS: A
Anesthesia and pain medication used in conjunction with the surgery are affecting the peristalsis of the bowel. Having a slower bowel, eating certain food, or lack of exercise will not have a direct effect on the bowel.

5. What is a primary prevention tool used for colon cancer screening?
a.
Abdominal x-rays
b.
Blood, urea, and nitrogen (BUN) testing
c.
Serum electrolytes
d.
Occult blood testing

ANS: D
Occult blood testing will reveal unseen blood in the stool, and this may signal a potentially serious bowel problem like colon cancer. BUN is used to evaluate kidney function. Serum electrolytes and abdominal x-rays are not related to colon cancer

1. During an assessment, the patient states that his bowel movements cause discomfort because the stool is hard and difficult to pass. As the nurse, you make which of the following suggestions to assist the patient with improving the quality of his bowel

ANS: A, B
Increasing fiber assists in adding bulk to the stool. Increasing water assists in softening the stool and moving it through the large intestine. Decreasing exercise will have the opposite effect of slowing bowel movements. Refraining from alcoho

2. When conducting a health history assessment, the nurse would want to know what most important information about the patient's elimination status? (Select all that apply.)
a.
Recent changes in elimination patterns
b.
Changes in color, consistency, or od

NS: A, B, D, E
Recent changes in elimination patterns, color, consistency, or odor are important for the nurse to know concerning elimination. Discomfort or pain during elimination is important for the nurse to know. A nurse should also know which medicat

5. The nurse is using different toileting schedules. Which principles will the nurse keep in mind when
planning care? (Select all that apply.)
a. Habit training uses a bladder diary.
b. Timed voiding is based upon the patient's urge to void.
c. Prompted v

ANS: A, C
Habit training is a toileting schedule based upon the patient's usual voiding pattern. Using a bladder diary, the usual times a patient voids are identified. It is at these times that the patient is then toileted. Prompted voiding is a program o

4. A nurse administers an antimuscarinic to a patient. Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.)
a. Decrease in dysuria
b. Decrease in urgency
c. Decrease in frequency
d. Decrease in p

ANS: B, C
When newly started on an antimuscarinic, you should monitor the patient for effectiveness, watching for a decrease in symptoms such as urgency, frequency, and urgency urinary incontinence episodes. Patients with painful urination are sometimes p

3. Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply.)
a. Increasing fluid intake
b. Dribbling of urine
c. Voiding in small amounts
d. Voiding within 6 hours of catheter removal
e. Burning with

ANS: B, C
Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts can indicate inadequate bladder emptying requiring intervention. All the rest are normal and do not r

2. The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions should the nurse take? (Select all that apply.)
a. Keeping the urine collection container on ice when indicated
b. Withholding all patient medications for the da

ANS: A, E
When obtaining a 24-hour urine specimen, it is important to keep the urine in cool conditions, depending upon the test. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held

1. Which nursing actions will the nurse implement when collecting a urine specimen from a patient? (Select all that apply.)
a. Growing urine cultures for up to 12 hours
b. Labeling all specimens with date, time, and initials
c. Allowing the patient adequa

ANS: B, C, E
All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Urine cultures can take up to 48 to 72 hours to develop. Only gloves are necessary to handle a urine specimen. Gown and

39. The nurse anticipates a suprapubic catheter for which patient?
a. A patient with recent prostatectomy
b. A patient with a urethral stricture
c. A patient with an appendectomy
d. A patient with menopause

ANS: B
A patient with a urethral stricture is most likely to have a suprapubic catheter. Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urological surgery). A patient with a recent

38. Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective?
a. Output that is smaller than the amount instilled
b. Blood clots or sediment in the drainage bag
c. Bright

ANS: C
If urine is bright red or has clots, increase irrigation rate until drainage appears pink, indicating successful irrigation. Expect more output than fluid instilled because of urine production. If output is smaller than the amount instilled, suspec

37. To reduce patient discomfort during a closed intermittent catheter irrigation, what should the nurse do?
a. Use room temperature irrigation solution.
b. Administer the solution as quickly as possible.
c. Allow the solution to sit in the bladder for at

ANS: A
To reduce discomfort use room temperature solution. Using cold solutions and instilling solutions too quickly can cause discomfort. During an irrigation, the solution does not sit in the bladder; it is allowed to drain. A container is not raised ab

36. A nurse is providing care to a group of patients. Which patient will the nurse see first?
a. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge inconti
b. A patient with reflex incontinence with elevated bl

ANS: B
The nurse should see the patient with reflex incontinence first. Patients with reflex incontinence are at risk for developing autonomic dysreflexia, a life-threatening condition that causes severe elevation of blood pressure and pulse rate and diap

35. A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)?
a. Drapes the urinary drainage tubing with no dependent lo

ANS: A
Avoid dependent loops in urinary drainage tubing. Prevent the urinary drainage bag from touching or dragging on the floor. When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot

34. A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection?
a. Maintaining a closed urinary drainage system
b. Inserting the catheter using strict clean technique
c.

ANS: A
A key intervention to prevent infection is maintaining a closed urinary drainage system. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgment and trauma, not infection. Disc

33. The nurse is preparing to apply an external catheter. Which action will the nurse take?
a. Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter.
b. Spiral wrap the penile shaft using adhesive tape to secure the cathete

ANS: A
When applying an external catheter, allow 2.5 to 5 cm (1 to 2 inches) of space between the tip of the penis and the end of the catheter. Spiral wrap the penile shaft with supplied elastic adhesive. The strip should not overlap. The elastic strip sh

32. A nurse is caring for a patient with a continent urinary reservoir. Which action will the nurse take?
a. Teach the patient how to self-cath the pouch.
b. Teach the patient how to perform Kegel exercises.
c. Teach the patient how to change the collecti

ANS: A
In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 t

31. A nurse is evaluating a nursing assistive personnel's (NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene?
a. Emptying the drainage bag when half full
b. Kinking the catheter tubing to obtain

ANS: C
Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder

30. The nurse will anticipate inserting a Coude? catheter for which patient?
a. An 8-year-old male undergoing anesthesia for a tonsillectomy
b. A 24-year-old female who is going into labor
c. A 56-year-old male admitted for bladder irrigation
d. An 86-yea

ANS: C
A Coude? catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coude? catheters are not indicated for children or women.

29. A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take?
a. Hold the shaft of the penis at a 60-degree angle.
b. Hold the shaft of the penis with the dominant hand.
c. Cleanse the meatus 3 times with th

ANS: D
Using the uncontaminated dominant hand, cleanse the meatus with cotton balls/swab sticks, using circular strokes, beginning at the meatus and working outward in a spiral motion. Repeat 3 times using a clean cotton ball/swabstick each time. With the

28. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?
a. "Set your alarm clock to wake you every 2 hours, so you can get

ANS: C
Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder

27. A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first?
a. Exiting the room and informing the patient that the nurse will return

ANS: B
To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A
patient should not be left alone on a bedpan

26. A nurse is watching a nursing assistive personnel (NAP) perform a post void bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up?
a. Palpates the patient's symphysis pubis
b. Wipes scanner head with a

ANS: D
The nurse will follow up if the NAP sets the scanner to female. Women who have had a hysterectomy should be designated as male. All the rest are correct and require no follow-up. The NAP should palpate the symphysis pubis, the scanner head should b

25. The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take?
a. Measure bladder before the patient voids.
b. Measure bladder within 10 minutes after the patient voids.
c. Measure bladder with he

ANS: B
Measurement should be within 10 minutes of voiding. It is a postvoid so the measurement is after the patient voids and the urine volume is recorded. Patient is supine with head slightly elevated.

24. Which statement by the patient about an upcoming contrast computed tomography (CT) scan indicates a need for further teaching?
a. "I will follow the food and drink restrictions as directed before the test is scheduled."
b. "I will be anesthetized so t

ANS: B
Patients are not put under anesthesia for a CT scan; instead, the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct and require no

23. A nurse is caring for a patient who just underwent an intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient?
a. Turn the patient on the right side to alleviate

ANS: C
Assess for delayed hypersensitivity to the contrast media. Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Therefore, the first nursing priority is to assess the patient for an all

22. A patient has severe flank pain. The urinalysis reveals presence of calcium phosphate crystals. The nurse will anticipate an order for which diagnostic test?
a. Intravenous pyelogram
b. Mid-stream urinalysis
c. Bladder scan
d. Cystoscopy

ANS: A
Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A mid-stream urinalysis is performed for a routine urinaly

21. Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine?
a. Reduced urine specific gravity
b. Increased blood pressure
c. Abnormal blood sugar
d. Fever with chills

ANS: D
Fever and chills may be observed. The presence of white blood cells in urine indicates a urinary tract infection or inflammation. Overhydration, early renal disease, and inadequate antidiuretic hormone secretion reduce specific gravity. Increased b

20. The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect?
a. Red color
b. Orange color
c. Dark amber color
d. intense yellow color

ANS: B
Some drugs change the color of urine (e.g., phenazopyridine�orange, riboflavin�intense yellow). Eating beets, rhubarb, and blackberries causes red urine. Dark amber urine is the result of high concentrations of bilirubin in patients with liver dise

19. A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection?
a. Casts
b. Protein
c. Crystals
d. Bacteria

ANS: D
Bacteria in the urine along with other symptoms support a diagnosis of urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal disease. Protein indicates kidney function and damage to the glomerular membrane

18. To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?
a. Cleanse the urethral meatus from the area of most contamination to least.
b. Initiate the first part of the urine stream directly into the

ANS: D
The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front to back). The initial stream flushes out microorgani

16. Which assessment question should the nurse ask if stress incontinence is suspected?
a. "Do you think your bladder feels distended?"
b. "Do you empty your bladder completely when you void?"
c. "Do you experience urine leakage when you cough or sneeze?

ANS: C
Stress incontinence can be related to intraabdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of the bladder would rule out retention and overflow. An inability to void compl

15. The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report?
a. Dysuria
b. Flank pain
c. Frequency
d. Fever

ANS: C
Cystitis is inflammation of the bladder; associated symptoms include hematuria, foul-smelling cloudy urine, and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection (bladder). Flank pain, fever, and chills are all signs

14. A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response?
a. Perform pelvic floor exercises.
b. Avoid voiding frequently.
c. Drink cranberry juice.
d. Wear an adult diaper.

ANS: A
Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Evidence has shown that patients with urgenc

13. A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
a. Throw the catheter way and begin again.
b. Fill the b

ANS: D
If no urine appears, the catheter may be in the vagina. If misplaced, leave the catheter in the vagina as a landmark to indicate where not to insert, and insert another sterile catheter. The catheter should be left in place until the new, sterile c

12. While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, which finding will the nurse expect?
a. An indwelling Foley catheter
b. Reddened irritated skin on buttocks
c. Tiny blood cl

ANS: B
Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often

11. A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
a. Obtaining a midstream urine specimen
b. Interpreting a bladder scan result
c. Inserting a straight catheter
d. Irrigating a cathe

ANS: A
The skill of collecting midstream (clean-voided) urine specimens can be delegated to nursing assistive personnel. The nurse must first determine the timing and frequency of the bladder scan measurement and interprets the measurements obtained. Inse

10. Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most appropriate?
a. "Does your urinary problem interfere with any activities?"
b. "Do you lose urine when you cough

ANS: C
To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended; time of last void is most appropriate. Further assessment to determine the pathology of

9. A nurse is caring for a male patient with urinary retention. Which action should the nurse take first?
a. Limit fluid intake.
b. Insert a urinary catheter.
c. Assist to a standing position.
d. Ask for a diuretic medication.

ANS: C
In some patients just helping them to a normal position to void prompts voiding. A urinary catheter would relieve urinary retention, but it is not the first measure; other nursing interventions should be tried before catheterization. Reducing fluid

8. A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem?
a. Limit fluid an

ANS: A
Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. To prevent nocturia, suggest that the patient avoid drinking fluids 2 hours before bedtime. Clearing a path to the bathroom, illuminating the path, or shortening

7. An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plan of care?
a. Functional urinary in

ANS: B
Functional urinary incontinence Urge urinary incontinence
Impaired skin integrity Urinary retention
Urge urinary incontinence is the leakage of urine associated with a strong urge to void. Patients leak urine on the way to or at the toilet and rush

6. The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria?
a. Blood in the urine
b. Burning upon urination
c. immediate, strong desire to void
d. Awakes from sleep due to urge to void

ANS: B
Dysuria is burning or pain with urination. Hematuria is blood in the urine. Urgency is an immediate and strong desire to void that is not easily deferred. Nocturia is awakening form sleep due to urge to void.

5. The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action?
a. The patient may void uncontrollably during the procedure.
b. Local trauma sometimes promotes excessive urine in

ANS: C
Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness, causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow, requi

4. A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?
a. The patient can be anxious, making it difficult for abdomina

ANS: A
Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. Anxiety can impact bladder emptying due to inadequate relaxation of the pelvic floor muscles and urinary sphincter. The nurse sh

3. A patient is experiencing oliguria. Which action should the nurse perform first?
a. Assess for bladder distention.
b. Request an order for diuretics.
c. Increase the patient's intravenous fluid rate.
d. Encourage the patient to drink caffeinated bevera

ANS: A
Oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the b

2. A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?
a. Protein level of 2 mg/100 mL
b. Urine output of 80 mL/hr
c. Specific gravity of 1.036
d. pH of 6.4

ANS: C
Dehydration, reduced renal blood flow, and increase in antidiuretic hormone secretion elevate specific gravity. Normal specific gravity is 1.0053 to 1.030. An output of 30 mL/hr or less for 2 or more hours would be cause for concern; 80 mL/hr is no

1. A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine?
a. Kidney, urethra, bladder, ureters
b. Kidney, ureters, bladder, urethra
c. Bladder, kidney, ureters, urethra
d.

ANS: B
The flow of urine follows these structures: kidney, ureters, bladder, and urethra.

1. The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients?
a. Ileum
b. Cecum
c. Stomach
d. Duodenum

ANS: D
The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine.

2. The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?
a. Sigmoid
b, Transverse
c. Ascending
d. Descending

ANS: C
The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool (very liquid) would be in the ascending.

3. A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion?
a. Cecum, ascending, transverse, descending, sigmoid, and rectum
b. Ascending, transverse, desce

ANS: A
The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination.

4. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (NAP)?
a. Performing the first postoperative pouch change
b. Maintaining a nasogastric tube
c. Administering an enema
d. Digitally r

ANS: C
The skill of administering an enema can be delegated to an NAP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an NAP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot

5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend?
a. Broccoli and cheese soup with potato bread
b. Turkey and mashed potatoes with brown gravy
c. Grape and wal

ANS: C
Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain as much fiber as whole wheat bread. A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole

6. A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient?
a. Long-te

ANS: A
Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of

7. A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement?
a. Preparing to administer a barium enema
b. Withholding narcotic p

ANS: D
Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A bariu

8. Which patient is most at risk for increased peristalsis?
a. A 5-year-old child who ignores the urge to defecate owing to embarrassment
b. A 21-year-old female with three final examinations on the same day
c. A 40-year-old female with major depressive d

ANS: B
Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constip

9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate?
a. "This is probably a false negative; we should rerun the test."
b. "You should schedule a colonoscopy as soon as

ANS: D
Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. The fecal occult test takes three separate samples over a period of time and is a

10. Which patient will the nurse assess most closely for an ileus? a. A patient with a fecal impaction
b. A patient with chronic cathartic abuse
c. A patient with surgery for bowel disease and anesthesia
d. A patient with suppression of hydrochloric acid

ANS: C
Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal impaction, cathartic abuse, and

11. A patient has a fecal impaction. Which portion of the colon will the nurse assess?
a. Descending
b. Transverse
c. Ascending
d. Rectum

ANS: D
A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transver

12. The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care?
a. A 25-year-old patient with diarrhea
b. A 40-year-old patient with an ileostomy
d. A 70-year-old patient with stool incontinence

ANS: D
The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for wh

13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs?
a. Administer a soapsuds enema every 2 hours.
b. Use a mobility device to place the patient on a bedside commode.
c. Give th

ANS: B
The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed is appropriate but is not the m

14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use.Which outcome will the nurse evaluate as successful for the patient to establish normal defecation?
a. The patient reports eliminating

ANS: A
The nurse's goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates

15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse
report immediately?
a. Liquid consistency of stool
b. Presence of blood in the stool
c. Malodorous stool
d. Continuous output from the stoma

ANS: B
Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous.

16. The nurse will anticipate which diagnostic examination for a patient with black tarry stools?
a. Ultrasound
b. Barium enema
c. Endoscopy
d. Anorectal manometry

ANS: C
Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization.

17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action?
a. Preparing the patient for a seco

ANS: B
When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient

18. A nurse is checking orders. Which order should the nurse question?
a. A normal saline enema to be repeated every 4 hours until stool is produced
b. A hypertonic solution enema for a patient with fluid volume excess
c. A Kayexalate enema for a patient

ANS: C
Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are inte

19. The nurse is performing a fecal occult blood test. Which action should the nurse take?
a. Test the quality control section before testing the stool specimens.
b. Apply liberal amounts of stool to the guaiac paper.
c. Report a positive finding to the p

ANS: C
Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section sho

20. A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important?
a. Ensuring that the patient does not eat or drink 2 hours before the examination.
b. Administering a colon cleansing product 6 hours b

ANS: D
No jewelry or metal products should be in the same room as an MRI machine because of the high- power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. P

22. Before administering a cleansing enema to an 80-year-old patient, the patient says "I don't think I will be able to hold the enema." Which is the next priority nursing action?
a. Rolling the patient into right-lying Sims' position
b. Positioning the p

ANS: B
If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient

23. A nurse is providing care to a group of patients. Which patient will the nurse see first?
a. A child about to receive a normal saline enema
b. A teenager about to receive loperamide for diarrhea
c. An older patient with glaucoma about to receive an en

ANS: C
An enema is contradicted in a patient with glaucoma; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for diarrhea. Docusate sodiu

24. A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression?
a. Salem sump
b. Small bore
c. Levin
d. 8 Fr

ANS: A
The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent. When the main lumen of the sump tube is connected to suction, the air vent permits

25. A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition of the new ostomy?
a. Eggs over easy, whole wheat toast, and orange juice with pulp
b. Chicken fried rice with fresh pin

ANS: C
During the first few days after ostomy placement, the patient should consume easy-to-digest soft foods such as poultry, rice, and noodles. Fried foods can irritate digestion. Foods high in fiber will be useful later in the recovery process but can

26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate?
a. Changing the skin barrier portion of the ostomy pouch daily
b. Emptying the pouch if it is more than one-third to one-half full
c. Thorough

ANS: B
Pouches must be emptied when they are one-third to one-half full because the weight of the pouch may disrupt the seal of the adhesive on the skin. The barrier device should be changed every 3 to 7 days unless it is leaking or is no longer effective

27. The nurse will irrigate a patient's nasogastric (NG) tube. Which action should the nurse take?
a. Instill solution into pigtail slowly.
b. Check placement after instillation of solution.
c. Immediately aspirate after instilling fluid.
d. Prepare 60 mL

ANS: C
After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue "pigtail" air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental

28. The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect?
a. Reports decreased diarrhea.
b. Experiences pain relief.
c. Has a bowel movement.
d. Passes flatulence.

ANS: C
A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic.
An antidiarrheal will provide relief from diarrhea.

29. An older adult's perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do?
a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap.
b. Tape an occlusive moistur

ANS: C
Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown.

30. Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient's nose from a nasogastric tube?
a. Instill Xylocaine into the nares once a shift.
b. Tape tube securely with light pressure on nare.
c. Lubricate t

ANS: C
The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to trea

31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education?
a. "If I get a blue color that means the test is negative."
b. "I should not get any u

ANS: A
A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not c

32. A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain?
a. Ewald
b. Dobhoff
c. Miller-Abbott
d. Sengstaken-Blakemore

ANS: A
Lavage is irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation. The types of tubes include Levin, Ewald, and Salem sump. Sengstaken-Blakemore is used for compression by internal application of pressure by means of i

33. The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria?
a. Appropriate disposal of contaminated items in biohazard bags
b. Monthly in-services about co

ANS: D
Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile c

34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding?
a. Hypoactive bowel sounds
b. Increased fluid intake
c. Soft tender abdomen
d. Jaundice in sclera

ANS: A
Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. Increased fluid intake would help the prob

35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect?
a. Distended abdomen
b. Decreased skin turgor
c. Increased energy levels
d. Elevated blood pressure

ANS: B
Chronic diarrhea can result in dehydration. Patients with chronic diarrhea are dehydrated with decreased skin turgor and blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abd

36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately?
a. Stoma is protruding from the abdomen.
b. Stoma is flush with the skin.
c. Stoma is purple.
d. Stoma is moist.

ANS: C
A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude.

37. A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve?
a. Prevent gaseous distention
b. Prevent constipation
c. Prevent colon infection
d. Prevent lower bowel inflammation

ANS: C
A medicated enema is a neomycin solution, i.e., an antibiotic used to reduce bacteria in the colon before bowel surgery. Carminative enemas provide relief from gaseous distention. Bulk forming, emollient (wetting), and osmotic laxatives and cathart

38. A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient's stool?
a. Bright red blood
b. Dark black blood
c. Microscopic
d. Mucoid

ANS: C
Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic). This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood,

39. A patient is receiving opioids for pain. Which bowel assessment is a priority?
a. c-diff
b. Constipation
c. Hemorrhoids
d. Diarrhea

ANS: B
Patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. C. difficile occurs from antibiotics, not opioids. Hemorrhoids are caused by conditions other than opioids. Diarrhea does not occu

40. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy?
a. Keep fiber low.
b. Eat large meals.
c. Increase fluid intake.
d. Chew food thoroughly.

ANS: C
Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass

1. A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.)
a. Record times when the patient is incontinent.
b. Help the patient to the toilet at the designated time.
c. Lean backward on the

ANS: A, B, D, F
A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is incontinent. Choosing a time based on the patient's pattern to initiate defecation-control measures. Maintaining

2. A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.)
a. A risk factor is smoking.
b. A risk factor is high intake of animal fats or red meat.
c. A warni

ANS: A, B, C, D
Risk factors for colorectal cancer are a diet high in animal fats or red meat and low intake of fruits and vegetables; smoking and heavy alcohol consumption are also risk factors. Warning signs are change in bowel habits, rectal bleeding,

1. The nurse is caring for a patient who is being discharged home after a splenectomy. What information on immune function needs to be included in this patient's discharge planning?
a.
The mechanisms of the inflammatory response
b.
Basic infection control

ANS: B
The spleen is one of the major organs of the immune system. Without the spleen, the patient is at higher risk for infection; so, the nurse must be sure that the patient understands basic principles of infection control. The patient with a splenecto

2. An 18-month-old female patient is diagnosed with her fifth ear infection in the past 10 months. The physician notes that the child's growth rate has decreased from the 60th percentile for height and weight to the 15th percentile over that same time per

ANS: A
Primary immunodeficiency is a risk for patients with two or more of the listed problems. Secondary immunodeficiency is induced by illness or treatment. Cancer is caused by abnormal cells that will trigger an immune response. Autoimmune diseases are

3. The nurse is caring for a postoperative patient who had an open appendectomy. The nurse understands that this patient should have some erythema and edema at the incision site 12 to 24 hours post operation dependent on which condition?
a.
His immune sys

ANS: A
Tissue integrity is closely associated with immunity. Openings in the integumentary system allow for the entrance of pathogens. If the immune response is functioning optimally, the body responds to the insult to the tissue by protecting the area fr

4. While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she makes which statement?
a.
"My body will treat the new kidney like my original kidney."
b.
"I will have to

ANS: C
Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will

5. The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patie

ANS: D
The patient is exhibiting signs and symptoms of an anaphylactic reaction to the medication. These signs and symptoms during administration of a medication do not correspond to a suppressed immune response but a type of hyperimmune response. While t

. The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse should explain which goal of treatment to the patient?
a.
Eradicate the disease
b.
Enhance immune response
c.
Control inflammation
d.
Manage pain

ANS: C
Medications for RA are intended to control the inflammation that results from the body's hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune

1. The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vacci

ANS: B, D, F
Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Immunizations are recommended for people a