NUR 325 Exam 2 Review Questions with Correct Answers (Grade
A+)
Question 1: Which of the following health conditions would be LEAST likely to cause fluid and
electrolyte imbalances?
a. Vomiting and diarrhea
b. Breaking a leg
c. Renal failure
d. Congestive heart failure (CHF)
Answer: B. Breaking a leg
Question 2: Which of the following group of symptoms would trigger you to think there may be some
fluid and electrolyte imbalances in your patient?
a. Tinnitus, erythema, shortness of breath
b. Petechiae, fever, low blood pressure
c. Unexplained nausea, dizziness, edema
d. Tachycardia, drowsiness, nausea
Answer: C. Unexplained nausea, dizziness, edema
Question 3: The patient talks with the nurse about bladder health. What is one of the most important
recommendations the nurse can make for this patient?
a. Eat foods high in fiber.
b. Drink 6 to 8 glasses of noncaffeinated fluids daily.
c. Exercise in the morning and evening.
d. Visit the urologist once yearly.
Answer: B (Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is
not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do
not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most
important recommendation from the nurse.)
Page 1
,Question 4: The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse
speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed
assistant understands the toileting procedure when making which statement?
a. The patient must remain in the restraints all day.
b. The patient needs to be toileted to maintain a regular toileting schedule.
c. The patient needs to be provided with adult briefs for incontinence.
d. The patient will use the call bell when he or she feels the urge to void.
Answer: B (The correct answer is toileting the patient so he or she can maintain a normal toileting schedule.
Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs
when he or she is not incontinent does not meet the patient's toileting needs. If the patient is confused, he or
she will not be able to use the call bell.)
Question 5: If a patient has a colostomy in the area known as the "ascending colon," what would the
nurse expect of the stool in the colostomy device?
a. Stool would be dark.
b. Stool would be formed.
c. Stool would be loose.
d. Stool would have flecks of blood.
Answer: C (The correct answer is C because stool in the ascending colon is loose or watery. Stool should
not be dark or have flecks of blood. This would be an abnormal finding. Stool would not be loose, because
the colon has not reabsorbed the water yet.)
Question 6: The nurse is talking with a patient who was just diagnosed with a urinary tract infection.
The patient asks the nurse how to prevent such infections in the future. The nurse should make which
appropriate recommendations for the patient? (Select all that apply.)
a. Drink 6 to 8 glasses of noncaffeinated fluids daily.
b. Exercise daily.
c. Increase fiber in the diet.
d. Void when the urge is felt.
e. Eat fruit twice daily.
Answer: A D (Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate
measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a
urinary tract infection.)
Page 2
,Question 7: When assessing a patient's first voided urine of the day, which finding should be reported
to the health care provider?
a. Pale yellow urine
b. Slightly cloudy urine
c. Light pink urine
d. Dark amber urine
Answer: C (Light pink urine indicates the presence of blood in the urine, which is never a normal finding.
First voided urine can normally be slightly cloudy and darker in color. Pale yellow urine indicates normal
finding.)
Question 8: What is a critical step when inserting an indwelling catheter into a male patient?
a. Slowly inflate the catheter balloon with sterile saline.
b. Secure the catheter drainage tubing to the bed sheets
c. Advance the catheter to the bifurcation of the drainage and balloon ports.
d. Advance the catheter until urine flows, then insert ¼ inch more.
Answer: C (Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic
urethra causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter
drainage tubing to the bed sheets increases the risk for accidental pulling or tension on the catheter. The
advancement of the catheter until flows and then inserting ¼ inch more is not unique to the male patient.)
Question 9: Which nursing intervention minimizes the risk for trauma and infection when applying an
external/condom catheter?
a. Leave a gap of 3-5 inches between the tip of the penis and drainage tube
b. Shave the pubic area so that hair does not adhere
c. Wash with soap and water prior to applying the condom type catheter.
d. Apply tape to the condom sheath to keep it securely in place.
Answer: C (Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space
between tip of the glans penis and the end of the catheter. Excess space may cause pooling of urine causing
excessive exposure to urine. Shaving the pubic area increases the risk for skin irritation. The condom should
be secure but not tight. Application of tape is contraindicated because it could interfere with circulation
increasing risk for necrosis of the penis.)
Question 10: What instructions should the nurse give the NAP concerning a patient who has had an
indwelling urinary catheter removed that day?
a. Limit oral fluid intake to avoid possible urinary incontinence.
b. Expect patient complaints of suprapubic fullness and discomfort.
c. Report the time and amount of first voiding.
d. Instruct patient to stay in bed and use a urinal or bedpan.
Answer: C (In order to adequately assess bladder function after a catheter is removed; voiding frequency
and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal
micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness
and pain are possible indicators of urinary retention and/or a UTI.)
Page 3
, Question 11: An ambulatory elderly woman with dementia is incontinent of urine. She has poor short
term memory and has not been seen toileting independently. What is the best nursing intervention for
this patient?
a. Recommend she be evaluated for an OAB medication.
b. Start a scheduled toileting program.
c. Recommend she be evaluated for an indwelling catheter.
d. Start a bladder retraining program
Answer: B (An appropriate first action would be to assess the patency of the drainage system. Urine output
in the drainage bag should be more than the volume of the irritant solution infused. If the system is not
draining urine and irritant, the irritant should be stopped immediately, the catheter may be occluded and the
bladder distended.)
Question 12: Which nursing assessment question would best indicate that an incontinent man with a
history of prostate enlargement might not be emptying his bladder adequately?
a. Do you leak urine when you cough or sneeze?
b. Do you need help getting to the toilet?
c. Do you dribble urine constantly?
d. Does it burn when you pass your urine?
Answer: C (Incontinence characterized by constant dribbling of urine is associated with incontinence
associated with urinary retention. . The other options point to stress incontinence, functional incontinence or
a UTI.)
Question 13: The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4
hours. What is a priority nursing intervention?
a. Implement the "as needed" order to irrigate the catheter.
b. Assess the catheter and drainage tubing for obvious occlusion.
c. Notify the health care provider immediately.
d. Assess the vital signs and intake and output record.
Answer: B (The priority nursing intervention is to ensure that there is not an occlusion in the catheter or
drainage tubing.)
Question 14: What nursing intervention decreases the risk for catheter associated urinary tract
infection (CAUTI)?
a. Cleanse the urinary meatus 3-4 times daily with antiseptic solution.
b. Hang the urinary drainage bag below the level with the bladder.
c. Empty the urinary drainage bag daily.
d. Irrigate the urinary catheter with sterile water.
Answer: B (Evidenced based interventions shown to decrease the risk for CAUTI include ensuring that
there is a free flow of urine from the catheter to the drainage bag.)
Page 4
A+)
Question 1: Which of the following health conditions would be LEAST likely to cause fluid and
electrolyte imbalances?
a. Vomiting and diarrhea
b. Breaking a leg
c. Renal failure
d. Congestive heart failure (CHF)
Answer: B. Breaking a leg
Question 2: Which of the following group of symptoms would trigger you to think there may be some
fluid and electrolyte imbalances in your patient?
a. Tinnitus, erythema, shortness of breath
b. Petechiae, fever, low blood pressure
c. Unexplained nausea, dizziness, edema
d. Tachycardia, drowsiness, nausea
Answer: C. Unexplained nausea, dizziness, edema
Question 3: The patient talks with the nurse about bladder health. What is one of the most important
recommendations the nurse can make for this patient?
a. Eat foods high in fiber.
b. Drink 6 to 8 glasses of noncaffeinated fluids daily.
c. Exercise in the morning and evening.
d. Visit the urologist once yearly.
Answer: B (Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is
not stagnating in the bladder. Exercising and eating foods high in fiber help with bowel elimination but do
not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most
important recommendation from the nurse.)
Page 1
,Question 4: The nurse is caring for a confused patient who is wearing a vest restraint in bed. The nurse
speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed
assistant understands the toileting procedure when making which statement?
a. The patient must remain in the restraints all day.
b. The patient needs to be toileted to maintain a regular toileting schedule.
c. The patient needs to be provided with adult briefs for incontinence.
d. The patient will use the call bell when he or she feels the urge to void.
Answer: B (The correct answer is toileting the patient so he or she can maintain a normal toileting schedule.
Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs
when he or she is not incontinent does not meet the patient's toileting needs. If the patient is confused, he or
she will not be able to use the call bell.)
Question 5: If a patient has a colostomy in the area known as the "ascending colon," what would the
nurse expect of the stool in the colostomy device?
a. Stool would be dark.
b. Stool would be formed.
c. Stool would be loose.
d. Stool would have flecks of blood.
Answer: C (The correct answer is C because stool in the ascending colon is loose or watery. Stool should
not be dark or have flecks of blood. This would be an abnormal finding. Stool would not be loose, because
the colon has not reabsorbed the water yet.)
Question 6: The nurse is talking with a patient who was just diagnosed with a urinary tract infection.
The patient asks the nurse how to prevent such infections in the future. The nurse should make which
appropriate recommendations for the patient? (Select all that apply.)
a. Drink 6 to 8 glasses of noncaffeinated fluids daily.
b. Exercise daily.
c. Increase fiber in the diet.
d. Void when the urge is felt.
e. Eat fruit twice daily.
Answer: A D (Drinking noncaffeinated drinks and voiding when the urge happens are the most appropriate
measures for avoiding a urinary tract infection. Increasing fiber, exercising, and eating fruit do not prevent a
urinary tract infection.)
Page 2
,Question 7: When assessing a patient's first voided urine of the day, which finding should be reported
to the health care provider?
a. Pale yellow urine
b. Slightly cloudy urine
c. Light pink urine
d. Dark amber urine
Answer: C (Light pink urine indicates the presence of blood in the urine, which is never a normal finding.
First voided urine can normally be slightly cloudy and darker in color. Pale yellow urine indicates normal
finding.)
Question 8: What is a critical step when inserting an indwelling catheter into a male patient?
a. Slowly inflate the catheter balloon with sterile saline.
b. Secure the catheter drainage tubing to the bed sheets
c. Advance the catheter to the bifurcation of the drainage and balloon ports.
d. Advance the catheter until urine flows, then insert ¼ inch more.
Answer: C (Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the prostatic
urethra causing trauma and pain. Catheter balloons are never inflated with saline. Securing the catheter
drainage tubing to the bed sheets increases the risk for accidental pulling or tension on the catheter. The
advancement of the catheter until flows and then inserting ¼ inch more is not unique to the male patient.)
Question 9: Which nursing intervention minimizes the risk for trauma and infection when applying an
external/condom catheter?
a. Leave a gap of 3-5 inches between the tip of the penis and drainage tube
b. Shave the pubic area so that hair does not adhere
c. Wash with soap and water prior to applying the condom type catheter.
d. Apply tape to the condom sheath to keep it securely in place.
Answer: C (Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space
between tip of the glans penis and the end of the catheter. Excess space may cause pooling of urine causing
excessive exposure to urine. Shaving the pubic area increases the risk for skin irritation. The condom should
be secure but not tight. Application of tape is contraindicated because it could interfere with circulation
increasing risk for necrosis of the penis.)
Question 10: What instructions should the nurse give the NAP concerning a patient who has had an
indwelling urinary catheter removed that day?
a. Limit oral fluid intake to avoid possible urinary incontinence.
b. Expect patient complaints of suprapubic fullness and discomfort.
c. Report the time and amount of first voiding.
d. Instruct patient to stay in bed and use a urinal or bedpan.
Answer: C (In order to adequately assess bladder function after a catheter is removed; voiding frequency
and amount should be monitored. Unless contraindicated, fluids should be encouraged. To promote normal
micturition, patients should be placed in as normal a posture for voiding as possible. Suprapubic tenderness
and pain are possible indicators of urinary retention and/or a UTI.)
Page 3
, Question 11: An ambulatory elderly woman with dementia is incontinent of urine. She has poor short
term memory and has not been seen toileting independently. What is the best nursing intervention for
this patient?
a. Recommend she be evaluated for an OAB medication.
b. Start a scheduled toileting program.
c. Recommend she be evaluated for an indwelling catheter.
d. Start a bladder retraining program
Answer: B (An appropriate first action would be to assess the patency of the drainage system. Urine output
in the drainage bag should be more than the volume of the irritant solution infused. If the system is not
draining urine and irritant, the irritant should be stopped immediately, the catheter may be occluded and the
bladder distended.)
Question 12: Which nursing assessment question would best indicate that an incontinent man with a
history of prostate enlargement might not be emptying his bladder adequately?
a. Do you leak urine when you cough or sneeze?
b. Do you need help getting to the toilet?
c. Do you dribble urine constantly?
d. Does it burn when you pass your urine?
Answer: C (Incontinence characterized by constant dribbling of urine is associated with incontinence
associated with urinary retention. . The other options point to stress incontinence, functional incontinence or
a UTI.)
Question 13: The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4
hours. What is a priority nursing intervention?
a. Implement the "as needed" order to irrigate the catheter.
b. Assess the catheter and drainage tubing for obvious occlusion.
c. Notify the health care provider immediately.
d. Assess the vital signs and intake and output record.
Answer: B (The priority nursing intervention is to ensure that there is not an occlusion in the catheter or
drainage tubing.)
Question 14: What nursing intervention decreases the risk for catheter associated urinary tract
infection (CAUTI)?
a. Cleanse the urinary meatus 3-4 times daily with antiseptic solution.
b. Hang the urinary drainage bag below the level with the bladder.
c. Empty the urinary drainage bag daily.
d. Irrigate the urinary catheter with sterile water.
Answer: B (Evidenced based interventions shown to decrease the risk for CAUTI include ensuring that
there is a free flow of urine from the catheter to the drainage bag.)
Page 4
