170 EXPH EXAM 3 WITH
100%COMPLETE ANSWERS
1. There is a 24-hr urine collection in process for a client. The nursing
assistive personnel (NAP) inadvertently empties one specimen into the
toilet instead of the collection "hat." The nurse should
A. Continue with the collection of urine until the 24-hr time period is finished.
B. Make a note to the lab to inform them that one specimen was missed
during the collection.
C. Begin filling a new collection container and take both containers to the lab
at the end of the collection period.
D. Dispose of the urine already collected and begin an entirely new 24-hr
collection - Ans--D. Dispose of the urine already collected and begin an
entirely new 24-hr collection.
• Once one specimen is missed during a 24-hr urine collection, the results of
the laboratory test will be inaccurate, and the collection must be restarted.
The female client states to the nurse, "I'm so distressed. It seems like every
time I laugh hard, I wet myself." The nurse knows that this condition is
known as
A. Stress incontinence
B. Urge incontinence
C. Functional incontinence
D. Unconscious incontinence - Ans--A. Stress incontinence
Stress incontinence results from increased pressure within the abdominal
cavity.
The nurse knows that the results of a fecal occult blood test can be
inaccurate if
1.The client has had an excessive intake of red meat.
,2.The female client is menstruating
3.The client takes high doses of vitamin C
4.All of the above - Ans--4.All of the above
Rationale: The results of a fecal occult blood test can be inaccurate for any
of the reasons given.
Mrs. Addie is 70 years old. While the nurse is gathering admission
assessment data, the patient states, "I've taken a tablespoon of Milk of
Magnesia every day for 3 years." Which nursing diagnosis is most
appropriate for the nurse to use in her plan of care?
1.Diarrhea
2.Constipation
3.Risk for Ineffective Therapeutic Regimen
4.Perceived Constipation - Ans--4.Perceived Constipation
Rationale: Daily laxative use by the patient might suggest that she
perceives she is constipated, and the nurse would gather further
assessment data related to the client's bowel pattern. There is not enough
data to infer actual constipation.
You are caring for a patient with a colostomy. In order to provide safe care
you understand that when irrigating a colostomy a proper fitting cone is
needed to prevent
1.Introducing air into the colon
2.Leaking the solution around the stoma
3.Administering the solution too rapidly
4.Introduction of bacteria from the stoma - Ans--2.Leaking the solution
around the stoma
Rationale: A proper fitting cone prevents leakage of the solution around the
stoma that may cause irritation and damage to the skin surrounding the
stoma.
,The nurse is assisting the client in caring for her ostomy. The client states,
"Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's
best response is
1."I'm sure you will get used to taking care of it eventually."
2."Yes, it is pretty messy, so I'll take care of it for you today."
3."It sounds like you are really upset."
4."You sound very angry. Should I call the chaplain for you?" - Ans--3."It
sounds like you are really upset."
Rationale: This statement reflects the principles of therapeutic
communication.
In meeting the safety needs of the adolescent client, it would be most
important for the nurse to focus his or her teaching on
1.Smoking cessation
2.Sports injuries
3.Alcohol abuse
4.Driver's education - Ans--4.Driver's education
Rationale: The leading cause of death for adolescents is motor vehicle
accidents.
A child has had hiccups for 2 hr. Is this a sign of suspected ingestion of
poison?
1.Yes
2.No - Ans--2.No
Rationale: Hiccups are not a sign of suspected ingestion of poison.
When implementing the use of restraints on a hospitalized client, the nurse
should
1.Restrain all confused clients so that they do not sustain a fall injury.
2.Tie the restraint to the bottom of the siderail so the client cannot reach it.
, 3.Ensure that the primary care provider renews the order for restraints once
every 24 hr.
4.Release the restraints and provide skin care at least once every shift. -
Ans--3.Ensure that the primary care provider renews the order for restraints
once every 24 hr.
Rationale: This statement meets the most current guidelines for the
provider's orders related to the use of restraints.
How would you, as the nurse, support a culture of safety? Select all that
apply.
1.Completing incident reports when appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident - Ans--1.Completing
incident reports when appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident
Key components of a culture of safety include:
• Team empowerment: Every individual has the opportunity to be heard,
feel important, and be a valued team member for the contribution offered.
• Communication: Open and honest lines of communication are needed
between the team members and from the team to other hospital units.
• Transparency: Team members are united in their efforts to eliminate
rumors and operate with only the facts, contributing to mutual team goals.
• Accountability: Claim ownership for human error and disclose the error to
help prevent similar errors; when an error is made own it, do not try to cover
it up.
The client has a draining abdominal wound that has become infected. In
caring for the client, the nurse will implement
A. Contact precautions
B. Droplet precautions
C. No precautions
100%COMPLETE ANSWERS
1. There is a 24-hr urine collection in process for a client. The nursing
assistive personnel (NAP) inadvertently empties one specimen into the
toilet instead of the collection "hat." The nurse should
A. Continue with the collection of urine until the 24-hr time period is finished.
B. Make a note to the lab to inform them that one specimen was missed
during the collection.
C. Begin filling a new collection container and take both containers to the lab
at the end of the collection period.
D. Dispose of the urine already collected and begin an entirely new 24-hr
collection - Ans--D. Dispose of the urine already collected and begin an
entirely new 24-hr collection.
• Once one specimen is missed during a 24-hr urine collection, the results of
the laboratory test will be inaccurate, and the collection must be restarted.
The female client states to the nurse, "I'm so distressed. It seems like every
time I laugh hard, I wet myself." The nurse knows that this condition is
known as
A. Stress incontinence
B. Urge incontinence
C. Functional incontinence
D. Unconscious incontinence - Ans--A. Stress incontinence
Stress incontinence results from increased pressure within the abdominal
cavity.
The nurse knows that the results of a fecal occult blood test can be
inaccurate if
1.The client has had an excessive intake of red meat.
,2.The female client is menstruating
3.The client takes high doses of vitamin C
4.All of the above - Ans--4.All of the above
Rationale: The results of a fecal occult blood test can be inaccurate for any
of the reasons given.
Mrs. Addie is 70 years old. While the nurse is gathering admission
assessment data, the patient states, "I've taken a tablespoon of Milk of
Magnesia every day for 3 years." Which nursing diagnosis is most
appropriate for the nurse to use in her plan of care?
1.Diarrhea
2.Constipation
3.Risk for Ineffective Therapeutic Regimen
4.Perceived Constipation - Ans--4.Perceived Constipation
Rationale: Daily laxative use by the patient might suggest that she
perceives she is constipated, and the nurse would gather further
assessment data related to the client's bowel pattern. There is not enough
data to infer actual constipation.
You are caring for a patient with a colostomy. In order to provide safe care
you understand that when irrigating a colostomy a proper fitting cone is
needed to prevent
1.Introducing air into the colon
2.Leaking the solution around the stoma
3.Administering the solution too rapidly
4.Introduction of bacteria from the stoma - Ans--2.Leaking the solution
around the stoma
Rationale: A proper fitting cone prevents leakage of the solution around the
stoma that may cause irritation and damage to the skin surrounding the
stoma.
,The nurse is assisting the client in caring for her ostomy. The client states,
"Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's
best response is
1."I'm sure you will get used to taking care of it eventually."
2."Yes, it is pretty messy, so I'll take care of it for you today."
3."It sounds like you are really upset."
4."You sound very angry. Should I call the chaplain for you?" - Ans--3."It
sounds like you are really upset."
Rationale: This statement reflects the principles of therapeutic
communication.
In meeting the safety needs of the adolescent client, it would be most
important for the nurse to focus his or her teaching on
1.Smoking cessation
2.Sports injuries
3.Alcohol abuse
4.Driver's education - Ans--4.Driver's education
Rationale: The leading cause of death for adolescents is motor vehicle
accidents.
A child has had hiccups for 2 hr. Is this a sign of suspected ingestion of
poison?
1.Yes
2.No - Ans--2.No
Rationale: Hiccups are not a sign of suspected ingestion of poison.
When implementing the use of restraints on a hospitalized client, the nurse
should
1.Restrain all confused clients so that they do not sustain a fall injury.
2.Tie the restraint to the bottom of the siderail so the client cannot reach it.
, 3.Ensure that the primary care provider renews the order for restraints once
every 24 hr.
4.Release the restraints and provide skin care at least once every shift. -
Ans--3.Ensure that the primary care provider renews the order for restraints
once every 24 hr.
Rationale: This statement meets the most current guidelines for the
provider's orders related to the use of restraints.
How would you, as the nurse, support a culture of safety? Select all that
apply.
1.Completing incident reports when appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident - Ans--1.Completing
incident reports when appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident
Key components of a culture of safety include:
• Team empowerment: Every individual has the opportunity to be heard,
feel important, and be a valued team member for the contribution offered.
• Communication: Open and honest lines of communication are needed
between the team members and from the team to other hospital units.
• Transparency: Team members are united in their efforts to eliminate
rumors and operate with only the facts, contributing to mutual team goals.
• Accountability: Claim ownership for human error and disclose the error to
help prevent similar errors; when an error is made own it, do not try to cover
it up.
The client has a draining abdominal wound that has become infected. In
caring for the client, the nurse will implement
A. Contact precautions
B. Droplet precautions
C. No precautions
