Fundamentals of Nursing NCLEX Practice Questions Quiz Set 3 | 75 Questions

Fundamentals of Nursing NCLEX Practice Questions Quiz Set 3 | 75 Questions 1. 1. Question The charge nurse asks the nursing assistive personnel (NAP) to give a bag bath to a patient with end-stage chronic obstructive pulmonary disease. How should the NAP proceed? o A. Bathe the patient's entire body using 8 to 10 washcloths. o B. Assist the patient to a chair and provide bathing supplies. o C. Saturate a towel and blanket in a plastic bag, and then bathe the patient. o D. Assist the patient to the bathtub and provide a bath chair. Incorrect Correct Answer: A. Bathe the patient’s entire body using 8 to 10 washcloths. A towel bath is a modification of the bed bath in which the NAP places a large towel and a bath blanket into a plastic bag, saturates them with a commercially prepared mixture of moisturizer, non rinse cleaning agent, and water; warms in them in a microwave, and then uses them to bathe the patient. A bag bath is a modification of the towel bath, in which the NAP uses 8 to 10 washcloths instead of a towel or blanket. Each part of the patient’s body is bathed with a fresh cloth. • Option B: A bag bath is not given in a chair or in the tub. The bag bath is one alternative to the traditional bed bath used in some nursing homes. The bath is performed with a series of 10 washcloths and a no-rinse liquid cleanser. Close the door and windows to prevent cold drafts and wash hands with warm water before beginning. • Option C: Moisten the washcloths with water and put in a plastic bag with the cleanser. Warm the bag in the microwave for 60 to 90 seconds. Test the temperature of the clothes before touching a resident with them and be careful when you open the bag, as steam can burn. • Option D: Take the bag to the resident’s bedside. When you are not cleaning a body part, keep it covered. Only expose as much of the resident’s body as necessary to adequately clean him or her. Be especially sensitive to exposing genitals, buttocks, and breasts. Bathing can be an extremely stressful experience for residents, so try to make it as easy as possible. 2. 2. Question For a morbidly obese patient, which intervention should the nurse choose to counteract the pressure created by the skin folds? • A. Cover the mattress with a sheepskin. • B. Keep the linens wrinkle free. • C. Separate the skin folds with towels. • D. Apply petrolatum barrier creams. Incorrect Correct Answer: C. Separate the skin folds with towels. Separating the skin folds with towels relieves the pressure of skin rubbing on skin. Skin folds, in particular, may be difficult for the patient to clean thoroughly; the abdominal folds and groins may be ignored, leading to an increased risk of skin breakdown in these areas. • Option A: Sheepskins are not recommended for use at all. Skin folds present a challenge in the management of patients who are morbidly obese. The weight from excess adipose tissue in skinfold areas can have an increased risk of skin injury such as friction, maceration, skin tears and pressure ulcer development. • Option B: Skin folds and areas vulnerable to skin injury should be cleaned and dried several times a day. Alcohol-based lotions and harsh soaps, as well as talcum powders, should be avoided in these areas. If necessary, dry cloths to absorb moisture can be left in skin folds in between washing and drying of the skin folds. • Option D: Petrolatum barrier creams are used to minimize moisture caused by incontinence. Patient hydration should also be considered in the nutrition plan for the patients and the health of their skin. 3. 3. Question A client exhibits all of the following during a physical assessment. Which of these is considered a primary defense against infection? • A. Fever • B. Intact skin • C. Inflammation • D. Lethargy Incorrect Correct Answer: B. Intact skin Intact skin is considered a primary defense against infection. Usually, the skin prevents invasion by microorganisms unless it is damaged (for example, by an injury, insect bite, or burn). Mucous membranes, such as the lining of the mouth, nose, and eyelids, are also effective barriers. Typically, mucous membranes are coated with secretions that fight microorganisms. For example, the mucous membranes of the eyes are bathed in tears, which contain an enzyme called lysozyme that attacks bacteria and helps protect the eyes from infection. Fever, the inflammatory response, and phagocytosis (a process of killing pathogens) are considered secondary defenses against infection. • Option A: Body temperature increases as a protective response to infection and injury. An elevated body temperature (fever) enhances the body’s defense mechanisms, although it can cause discomfort. A part of the brain called the hypothalamus controls body temperature. Fever results from an actual resetting of the hypothalamus’s thermostat. The body raises its temperature to a higher level by moving (shunting) blood from the skin surface to the interior of the body, thus reducing heat loss. • Option C: Any injury, including an invasion by microorganisms, causes inflammation in the affected area. Inflammation, a complex reaction, results from many different conditions. During inflammation, the blood supply increases, helping carry immune cells to the affected area. Because of the increased blood flow, an infected area near the surface of the body becomes red and warm. The walls of blood vessels become more porous, allowing fluid and white blood cells to pass into the affected tissue. The increase in fluid causes the inflamed tissue to swell. The white blood cells attack the invading microorganisms and release substances that continue the process of inflammation. • Option D: Lethargy refers to a state of lacking energy. People who are experiencing fatigue or tiredness can also be said to be lethargic because of low energy. The same medical conditions that can lead to tiredness or fatigue can also lead to lethargy. 4. 4. Question A client with a stage 2 pressure ulcer has methicillin-resistant Staphylococcus aureus (MRSA) cultured from the wound. Contact precautions are initiated. Which rule must be observed to follow contact precautions? • A. A clean gown and gloves must be worn when in contact with the client. • B. Everyone who enters the room must wear a N-95 respirator mask. • C. All linen and trash must be marked as contaminated and send to biohazard waste. • D. Place the client in a room with a client with an upper respiratory infection. Incorrect Correct Answer: A. A clean gown and gloves must be worn when in contact with the client. A clean gown and gloves must be worn when any contact is anticipated with the client or with contaminated items in the room. Visitors might also be asked to wear a gown and gloves. Patients are asked to stay in their hospital rooms as much as possible. They should not go to common areas, such as the gift shop or cafeteria. They may go to other areas of the hospital for treatments and tests. • Option B: A respirator mask is required only with airborne precautions, not contact precautions. Healthcare providers will put on gloves and wear a gown over their clothing while taking care of patients with MRSA. • Option C: All linen must be double-bagged and clearly marked as contaminated. When leaving the room, healthcare providers and visitors remove their gown and gloves and clean their hands. • Option D: The client should be placed in a private room or in a room with a client with an active infection caused by the same organism and no other infections. Whenever possible, patients with MRSA will have a single room or will share a room only with someone else who also has MRSA. 5. 5. Question A client requires protective isolation. Which client can be safely paired with this client in a client-care assignment? One: • A. Admitted with unstable diabetes mellitus. • B. Who underwent surgical repair of a perforated bowel. • C. With a stage 3 sacral pressure ulcer. • D. Admitted with a urinary tract infection. Incorrect Correct Answer: A. Admitted with unstable diabetes mellitus. The client with unstable diabetes mellitus can safely be paired in a client-care assignment because the client is free from infection. Protective Isolation aims to protect an immunocompromised patient who is at high risk of acquiring micro-organisms from either the environment or from other patients, staff, or visitors. • Option B: Perforation of the bowel exposes the client to infection requiring antibiotic therapy during the postoperative period. Therefore, this client should not be paired with a client in protective isolation. Patients should remain in isolation whilst they remain symptomatic; a risk assessment should be undertaken to ascertain if and when isolation precautions can be relaxed. • Option C: A client in protective isolation should not be paired with a client who has an open wound, such as a stage 3 pressure ulcer. Patient’s requiring protective isolation should be nursed in a single room. Where possible this room should have an ante-room, positive pressure ventilation and Hepa filtered air. The room should have an en-suite and hand washing facilities and the doors(s) should be kept closed at all times. • Option D: A client in protective isolation should not be paired with a client who has a urinary tract infection. Many infections acquired by immunocompromised patients are endogenous infections (An infection caused by an infectious agent that is already present in the body but has previously been inapparent or dormant), however, the transmission of infection from other patients, staff, or the environment can be a risk and therefore extra precautions are required. 6. 6. Question A newly hired at Nurseslabs Medical Center is assigned to the OR Department. Which action demonstrates a break in sterile technique? • A. Remaining 1 foot away from non sterile areas. • B. Placing sterile items on the sterile field. • C. Avoiding the border of the sterile drape. • D. Reaching 1 foot over the sterile field. Incorrect Correct Answer: D. Reaching 1 foot over the sterile field. Reaching over the sterile field while wearing sterile garb breaks the sterile technique. While observing sterile technique, healthcare workers should remain 1 foot away from non-sterile areas while wearing sterile garb, place sterile items needed for the procedure on the sterile drape, and avoid coming in contact with the 1-inch border of the sterile drape. The principles of the Sterile Technique are applied in various ways. If the principle itself is understood, the applications of it become obvious. A strict aseptic technique is needed at all times in the Operating Room. • Option A: Sterile persons avoid leaning over an unsterile area; non-sterile persons avoid reaching over a sterile field. Unsterile persons do not get closer than 12 inches from a sterile field. • Option B: Persons who are sterile touch only sterile articles; persons who are not sterile touch only unsterile articles. If in doubt about the sterility of anything consider it not sterile. If a non-sterile person brushes close consider yourself contaminated. • Option C: Sterile persons keep contact with sterile areas to a minimum. Do not lean on the sterile tables or on the draped patient. Do not lean on the nurse’s mayo tray. 7. 7. Question Nurse Berta is facilitating a monthly mothers’ class at a small village. As a knowledgeable nurse, she must know that a mother who breastfeeds her child passes on which antibody through breast milk? • A. IgA • B. IgE • C. IgG • D. IgM Incorrect Correct Answer: A. IgA Antibodies, which are also called immunoglobulins, take five basic forms, indicated as IgG, IgA, IgM, IgD and IgE. All have been detected in human milk, but by far the most abundant type is IgA, particularly the form known as secretory IgA, which is found in great amounts throughout the gut and respiratory system of adults. The secretory IgA molecules passed to the suckling child are helpful in ways that go beyond their ability to bind to microorganisms and keep them away from the body’s tissues. • Option B: IgE is a monomer. It has a molecular weight of 188 Kd and a serum concentration of 0.00005 mg/mL. It protects against parasites and also binds to high-affinity receptors on mast cells and basophils causing allergic reactions. IgE is regarded as the most important host defense against different parasitic infections which include Strongyloides stercoralis, Trichinella spiralis, Ascaris lumbricoides, and the hookworms Necator americanus and Ancylostoma duodenal. • Option C: IgG2 forms an important host defense against bacteria that are encapsulated. IgG is the only immunoglobulin that crosses the placentae as its Fc portion binds to the receptors present on the surface of the placenta, protecting the neonate from infectious diseases. IgG is thus the most abundant antibody present in newborns. • Option D: IgM has a molecular weight of 970 Kd and an average serum concentration of 1.5 mg/ml. It is mainly produced in the primary immune response to infectious agents or antigens. It is a pentamer and activates the classical pathway of the complement system. IgM is regarded as a potent agglutinin (e.g., anti-A and anti-B isoagglutinin present in type B and type A blood respectively) and a monomer of IgM is used as a B cell receptor (BCR). 8. 8. Question The clinical instructor asks her students the rationale for handwashing. The students are correct if they answered that handwashing is expected to remove: • A. Transient flora from the skin • B. Resident flora from the skin • C. All microorganisms from the skin • D. Media for bacterial growth Incorrect Correct Answer: A. Transient flora from the skin There are two types of normal flora: transient and resident. Transient flora are normal flora that a person picks up by coming in contact with objects or another person (e.g., when you touch a soiled dressing). You can remove these with hand washing. Hand washing can prevent about 30% of diarrhea-related illnesses and about 20% of respiratory infections (e.g., colds). Antibiotics often are prescribed unnecessarily for these health issues • Option B: Resident flora live deep in skin layers where they live and multiply harmlessly. They are permanent inhabitants of the skin and cannot usually be removed with routine hand washing. • Option C: Removing all microorganisms from the skin (sterilization) is not possible without damaging the skin tissues. To live and thrive in humans, microbes must be able to use the body’s precise balance of food, moisture, nutrients, electrolytes, pH, temperature, and light. • Option D: Food, water, and soil that provide these conditions may serve as nonliving reservoirs. Hand washing does little to make the skin uninhabitable for microorganisms, except perhaps briefly when an antiseptic agent is used for cleansing. Handwashing with soap could protect about 1 out of every 3 young children who get sick with diarrhea and almost 1 out of 5 young children with respiratory infections like pneumonia. 9. 9. Question Which of the following incidents requires the nurse to complete an occurrence report? • A. Medication given 30 minutes after scheduled dose time. • B. Patient's dentures lost after transfer. • C. Worn electrical cord discovered on an IV infusion pump. • D. Prescription without the route of administration. Incorrect Correct Answer: B. Patient’s dentures lost after transfer You would need to complete an occurrence report if you suspect your patient’s personal items to be lost or stolen. An incident report also provides vital information the facility needs to decide whether restitution should be made—if personal belongings were lost or damaged, for example. Without proper documentation of the incident, there’s no way to make these important decisions effectively. • Option A: A medication can be administered within a half-hour of the administration time without an error in administration; therefore, an occurrence report is not necessary. An incident report invariably makes its way to risk managers and other administrators, who review it rapidly and act quickly to change any policy or procedure that appears to be a key contributing factor to the incident. • Option C: The worn electrical cord should be taken out of use and reported to the biomedical department. An incident report should be filed whenever an unexpected event occurs. The rule of thumb is that any time a patient makes a complaint, a medication error occurs, a medical device malfunctions, or anyone—patient, staff member, or visitor—is injured or involved in a situation with the potential for injury, an incident report is required. • Option D: The nurse should seek clarification if the provider’s order is missing information; an occurrence report is not necessary. The medical record is patient-focused, and facts pertinent to an unexpected incident will likely be left out. So if a claim were filed and the case proceeded to court, which sometimes occurs years after the event, you or anyone else involved might be hard-pressed to recreate the scene—especially if you consider it to be “minor” at the time. You may not be able to rely on memory alone, but you can count on the incident report to refresh your memory. 10. 10. Question The nurse is orienting a new nurse to the unit and reviews source-oriented charting. Which statement by the nurse best describes source-oriented charting? Source-oriented charting: • A. Separates the health record according to discipline. • B. Organizes documentation around the patient's problems. • C. Highlights the patient's concerns, problems, and strengths. • D. Is designed to streamline documentation. Incorrect Correct Answer: A. Separates the health record according to discipline In source-oriented charting, each discipline documents findings in a separately labeled section of the chart. Source-oriented (SO) charting is a narrative recording by each member (source) of the health care team charts on separate records. SO charting is time-consuming and can lead to fragmented care. Effective documentation requires the use of common vocabulary; legibility and neatness; the use of only authorized abbreviations and symbols; factual and time-sequenced organization; and accuracy, including any errors that occurred. All documents related to client care are confidential and clients must sign a release to have their information released, specifying what type of information may be released and to whom it may be released. • Option B: Problem-oriented charting organizes notes around the patient’s problems. POMR is a structured, logical format of narrative charting, using “SOAP,” where S means “subjective data,” O means “objective data,” A means assessment data, and P means “plan.” Some institutions add, intervention, E, evaluation, and R, revision, to the SOAP format. POMR is sometimes altered to become a problem-oriented record (POR). The critical components of POMR/POR are the database; the problem list; the initial plan; and the progress notes, based on the SOAP, SOAPIE, or SOAPIER format. • Option C: Focus charting highlights the patient’s concerns, problems, and strengths. Focus Charting of F-DAR is intended to make the client and client concerns and strengths the focus of care. It is a method of organizing health information in an individual’s record. Focus Charting is a systematic approach to documentation. • Option D: Charting by exception is a unique charting system designed to streamline documentation. Charting by exception (CBE) is a shorthand method of documenting normal findings, based on clearly defined normals, standards of practice, and predetermined criteria for assessments and interventions. Significant findings or exceptions to the predefined norms are documented in detail. 11. 11. Question When the nurse completes the patient’s admission nursing database, the patient reports that he does not have any allergies. Which acceptable medical abbreviation can the nurse use to document this finding? • A. NA • B. NDA • C. NKA • D. NPO Incorrect Correct Answer: C. NKA The nurse can use the medical abbreviation NKA, which means no known allergies, to document this finding. NKA is the abbreviation for “no known allergies,” meaning no known allergies of any sort. By contrast, NKDA stands exclusively for “no known drug allergies.” • Option A: NA is an abbreviation for not applicable. • Option B: NDA is an abbreviation for no known drug allergies. • Option D: NPO is an abbreviation that means nothing by mouth. 12. 12. Question The nurse is working on a unit that uses nursing assessment flow sheets. Which statement best describes this form of charting? Nursing assessment flow sheets: • A. Are comprehensive charting forms that integrate assessments and nursing actions. • B. Contain only graphic information, such as I&O, vital signs, and medication administration. • C. Are used to record routine aspects of care; they do not contain assessment data. • D. Contain vital data collected upon admission, which can be compared with newly collected data. Incorrect Correct Answer: A. Are comprehensive charting forms that integrate assessments and nursing actions Nursing assessment flow sheets are organized by body systems. The nurse checks the box corresponding to the current assessment findings. Nursing actions, such as wound care, treatments, or IV fluid administration, are also included. A flow sheet is simply a one- or two-page form that gathers all the important data regarding a patient’s condition. The flow sheet is housed in the patient’s chart and serves as a reminder of care and a record of whether care expectations have been met. • Option B: Graphic information, such as vital signs, I&O, and routine care, may be found on the graphic record. This where records of serial measurements and observations, nursing interventions, and nursing care plans are recorded. • Option C: Nursing documentation covers a wide variety of issues, topics, and systems. Researchers, practitioners, and hospital administrators view recordkeeping as an important element leading to continuity of care, safety, quality care, and compliance. • Option D: The admission form contains baseline information. In health care organizations, the EHR, oral reports, handoffs, conferences, and health information technologies (HIT) are intended to facilitate information flow. In particular, the JCAHO specifically conceptualizes the care planning process as the structuring framework for coordinating communication that will result in safe and effective care. 13. 13. Question At the end of the shift, the nurse realizes that she forgot to document a dressing change that she performed for a patient. Which action should the nurse take? • A. Complete an occurrence report before leaving. • B. Do nothing; the next nurse will document it was done. • C. Write the note of the dressing change into an earlier note. • D. Make a late entry as an addition to the narrative notes. Incorrect Correct Answer: D. Make a late entry as an addition to the narrative notes. If the nurse fails to make an important entry while charting, she should make a late entry as an addition to the narrative notes. The nurse can only document care directly performed or observed. Therefore, the nurse on the incoming shift would not record the wound change as performed. A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care. • Option A: An occurrence report is not necessary in this case. The issue of completeness is important; Croke cites failure to document as one of the six top reasons that nurses face malpractice suits. In terms of overall completeness, Stokke and Kalfoss found many gaps in nursing documentation in Norway. Care plans, goals, diagnoses, planned interventions, and projected outcomes were absent between 18 percent and 45 percent of the time. • Option B: If documentation is omitted, there is no legal verification that the procedure was performed. Completeness of a record may have an impact on the quality of care, but only if it reflects completeness of the right content. Echoed again here is that document focus, rather than the patient-centric nature of the medical record, does little to support shared understanding by clinicians of care and the communication needed to ensure the continuity, quality, and safety of care. • Option C: It is illegal to add to a chart entry that was previously documented. The typical content and format of documentation—and its lack of accessibility—have also resulted in document-centric rather than patient-centric records. 14. 14. Question Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system? • A. It includes organizational reports of unusual occurrences that are not part of the client's record. • B. This type of system consists of combined documentation and daily care plans. • C. It improves interdisciplinary collaboration that improves efficiency in procedures. • D. This type of system tracks medication administration and usage over 24 hours. Incorrect Correct Answer: C. It improves interdisciplinary collaboration that improves efficiency in procedures. The EHR has several benefits for users, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports The EHR automates access to information and has the potential to streamline the clinician’s workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting. • Option A: An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. The purpose of the incident report is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident. • Option B: Integrated plans of care (IPOC) are a combined charting and care plan format. It is care that is planned with people who work together to understand the service user and their carer(s), puts them in control, and coordinates and delivers services to achieve the best outcomes • Option D: A medication administration record (MAR) is used to document medications administered and their usage. A Medication Administration Record (MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a healthcare professional. The MAR is a part of a patient’s permanent record on their medical chart. 15. 15. Question In the United States, the first programs for training nurses were affiliated with: • A. The military • B. General hospitals • C. Civil service • D. Religious orders Incorrect Correct Answer: D. Religious orders When the Civil War broke out, the Army used nurses who had already been trained in religious orders. Nursing started with religious orders. The Hindu faith was the first to write about nursing. In the United States, all training for nurses was affiliated with religious orders until after the Civil War. • Option A: Although the Army did provide some training, it occurred later than in the religious orders. Most people think of the nursing profession as beginning with the work of Florence Nightingale, an upper class British woman who captured the public imagination when she led a group of female nurses to the Crimea in October of 1854 to deliver nursing service to British soldiers. • Option B: Although nurses were trained in hospitals, the training and the hospitals were affiliated with religious orders. Upon her return to England, Nightingale successfully established nurse education programs in a number of British hospitals. These schools were organized around a specific set of ideas about how nurses should be educated, developed by Nightingale often referred to as the “Nightingale Principles.” • Option C: Civil service was not mentioned in Chapter 1 and was not a factor in the early 1800s. While Nightingale’s work was groundbreaking in that she confirmed that a corps of educated women, informed about health and the ways to promote it, could improve the care of patients based on a set of particular principles, she was not the first to put these principles into action. 16. 16. Question Which of the following is/are an example(s) of a health restoration activity? Select all that apply. • A. Administering an antibiotic every day. • B. Teaching the importance of handwashing. • C. Assessing a client's surgical incision. • D. Advising a woman to get an annual mammogram after age 50 years. • E. Attending rehabilitation of a fractured arm. Incorrect Correct Answer: A, C, E Health restoration activities help an ill client return to health. This would include taking an antibiotic every day and assessing a client’s surgical incision. Hand washing and mammograms both involve healthy people who are trying to prevent illness. • Option A: Rehabilitation or restoration is defined as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”. • Option B: Disease prevention, understood as specific, population-based, and individual-based interventions for primary and secondary (early detection) prevention, aiming to minimize the burden of diseases and associated risk factors. • Option C: Rehabilitation helps a child, adult, or older person to be as independent as possible in everyday activities and enables participation in education, work, recreation, and meaningful life roles such as taking care of a family. It does so by addressing underlying conditions (such as pain) and improving the way an individual function in everyday life, supporting them to overcome difficulties with thinking, seeing, hearing, communicating, eating, or moving around. • Option D: Secondary prevention deals with early detection when this improves the chances for positive health outcomes (this comprises activities such as evidence-based screening programs for early detection of diseases or for prevention of congenital malformations; and preventive drug therapies of proven effectiveness when administered at an early stage of the disease). • Option E: Rehabilitation is highly person-centered, meaning that the interventions and approach selected for each individual depends on their goals and preferences. Rehabilitation can be provided in many different settings, from inpatient or outpatient hospital settings to private clinics, or community settings such as an individual’s home. 17. 17. Question Which of the following aspects of nursing is essential to defining it as both a profession and a discipline? • A. Established standards of care • B. Professional organizations • C. Practice supported by scientific research • D. Activities determined by a scope of practice Incorrect Correct Answer: C. Practice supported by scientific research A profession must have knowledge that is based on technical and scientific knowledge. The theoretical knowledge of a discipline must be based on research, so both are scientifically based. The profession of nursing consists of persons educated in the discipline according to nationally regulated, defined, and monitored standards. The standards and regulations are to preserve healthcare safety for members of society. Although the discipline and the profession of nursing have different goals, the raison d’être of nursing is the enhancement of quality of life for humankind. The discipline provides the science lived in the art of practice. • Option A: The American Nurses Association (ANA) has developed standards of care, but they are unrelated to defining nursing as a profession or discipline. Nursing is a discipline and a profession. The goal of the discipline is to expand knowledge about human experiences through creative conceptualization and research. This knowledge is the scientific guide to living the art of nursing. The discipline-specific knowledge is given birth and fostered in academic settings where research and education move the knowledge to new realms of understanding. • Option B: Having professional organizations is not included in accepted characteristics of either a profession or a discipline. The goal of the profession is to provide service to humankind through living the art of science. Members of the nursing profession are responsible for regulation of standards of practice and education based on disciplinary knowledge that reflects safe health service to society in all settings. • Option D: Having a scope of practice is not included in accepted characteristics of either a profession or a discipline. The discipline of nursing encompasses the knowledge in the extant frameworks and theories that are embedded in the totality and simultaneity paradigms (Parse, 1987). These theories and frameworks explicate the nature of nursing’s major phenomenon of concern, the human-universe-health process. 18. 18. Question The charge nurse on the medical-surgical floor assigns vital signs to the nursing assistive personnel (NAP) and medication administration to the licensed vocational nurse (LVN). Which nursing model of care is this floor following? • A. Team nursing • B. Case method nursing • C. Functional nursing • D. Primary nursing Incorrect Correct Answer: C. Functional nursing This medical-surgical floor is following the functional nursing model of care, in which care is partitioned and assigned to a staff member with the appropriate skills. For example, the NAP is assigned vital signs, and the LVN is assigned medication administration. Functional nursing is task-oriented in scope. Instead of one nurse performing many functions, several nurses are given one or two assignments. For example, there is a medicine nurse whose sole responsibility is administering medications. • Option A: With team nursing, an RN or LVN is paired with a NAP. The pair is then assigned to render care for a group of patients. Team nursing is a system that distributes the care of a patient amongst a team that is all working together to provide for this person. This team consists of up to 4 to 6 members that has a team leader who gives jobs and instructions to the group. • Option B: In case method nursing, one nurse cares for one patient during her entire shift. Private duty nursing is an example of this care model. The case method is a participatory, discussion-based way of learning where students gain skills in critical thinking, communication, and group dynamics. It is a type of problem-based learning. • Option D: When the primary nursing model is utilized, one nurse manages care for a group of patients 24 hours a day, even though others provide care during part of the day. A method of providing nursing services to inpatients whereby one nurse plans the care of specific patients for a period of 24 hours. The primary nurse provides direct care to those patients when working and is responsible for directing and supervising their care in collaboration with other health care team members. 19. 19. Question Paul Jake suffered a stroke and has difficulty swallowing. Which healthcare team member should be consulted to assess the patient’s risk for aspiration? • A. Respiratory therapist • B. Occupational therapist • C. Dentist • D. Speech therapist Incorrect Correct Answer: D. Speech therapist Speech and language therapists provide assistance to clients experiencing swallowing and speech disturbances. They assess the risk for aspiration and recommend a treatment plan to reduce the risk. Speech-language pathologists (SLPs) work to prevent, assess, diagnose, and treat speech, language, social communication, cognitive-communication, and swallowing disorders in children and adults. • Option A: Respiratory therapists provide care for patients with respiratory disorders. Respiratory therapists interview and examine patients with breathing or cardiopulmonary disorders. Respiratory therapists care for patients who have trouble breathing—for example, from a chronic respiratory disease, such as asthma or emphysema. • Option B: Occupational therapists help patients regain function and independence. Occupational therapists treat injured, ill, or disabled patients through the therapeutic use of everyday activities. They help these patients develop, recover, improve, as well as maintain the skills needed for daily living and working. • Option C: Dentists diagnose and treat dental disorders. Dentists remove tooth decay, fill cavities, and repair fractured teeth. Dentists diagnose and treat problems with patients’ teeth, gums, and related parts of the mouth. They provide advice and instruction on taking care of the teeth and gums and on diet choices that affect oral health. 20. 20. Question Which of the following is/are an example(s) of theoretical knowledge? Select all that apply. • A. Antibiotics are ineffective in treating viral infections. • B. When you take a patient's blood pressure, the patient's arm should be at heart level. • C. In Maslow's framework, physical needs are most basic. • D. When drawing medication out of a vial, inject air into the vial first. • E. Let the patient dangle his feet first before assisting him to stand or transfer. Incorrect Correct Answer: A, C Theoretical knowledge consists of research findings, facts (e.g., “Antibiotics are ineffective . . .” is a fact), principles, and theories (e.g., “In Maslow’s framework . . .” is a statement from a theory). Instructions for taking blood pressure and withdrawing medications are examples of practical knowledge—what to do and how to do it. While practical knowledge is gained by doing things, theoretical knowledge is gained, for example, by reading a manual. • Option A: Theoretical knowledge teaches the reasoning, techniques and theory of knowledge. • Option B: Practical knowledge is the knowledge that is acquired by day-to-day hands-on experiences. In other words, practical knowledge is gained through doing things; it is very much based on real-life endeavors and tasks. • Option C: While theoretical knowledge may guarantee that you understand the fundamental concepts and have know-how about how something works and its mechanism, it will only get you so far, as, without practice, one is not able to perform the activity as well as he could. • Option D: Practical knowledge guarantees that you are able to actually do something instead of simply knowing how to do it. • Option E: Theoretical and practical knowledge are interconnected and complement each other — if one knows exactly HOW to do something, one must be able to apply these skills and therefore succeed in practical knowledge. 21. 21. Question The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? • A. The bladder distends and its capacity increases. • B. Older adults ignore the need to void. • C. Urine becomes more concentrated. • D. The amount of urine retained after voiding increases. Incorrect Correct Answer: D. The amount of urine retained after voiding increases The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained. Muscle changes and changes in the reproductive system can affect bladder control. As the volume of urine held by the bladder increases, so too does the pressure therein. Wall pressure of 5 to 15 mm Hg creates a sensation of bladder fullness while 30 mm Hg and beyond is painful. The sensation of increasing bladder fullness is conveyed to the spinal cord via the pudendal and hypogastric nerves on both A-delta and C nerve fibers. • Option A: The bladder wall changes. The elastic tissue becomes tough and the bladder becomes less stretchy. The bladder cannot hold as much urine as before. The urethra can become blocked. In women, this can be due to weakened muscles that cause the bladder or vagina to fall out of position (prolapse). In men, the urethra can become blocked by an enlarged prostate gland. • Option B: Older adults don’t ignore the urge to void and may have difficulty getting to the toilet in time. Bladder capacity changes throughout one’s life. In children, an approximation of bladder volume can be calculated with the formula: (years of age + 2) x 30 mL. By adulthood, the average volume that a functional bladder can comfortably hold is between 300 and 400 mL. • Option C: The kidney becomes less able to concentrate urine with age. Urination or micturition primarily functions in the excretion of metabolic products and toxic wastes. The urinary tract also serves as a storage vessel of the waste filtered from the kidneys. Urine stored in the bladder is released from the bladder through the urethra upon a complex network of neurological function. 22. 22. Question During the assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. • A. Perineal skin irritation • B. Fluid intake of less than 1,500 mL/d • C. History of antihistamine intake • D. Hx of UTI • E. A fecal impaction Incorrect Correct Answer: A, B, D, and E Urinary incontinence is the involuntary leakage of urine. This medical condition is common in the elderly, especially in nursing homes, but it can affect younger adult males and females as well. Urinary incontinence can impact both patient health and quality of life. The prevalence may be underestimated as some patients do not inform health care providers of having issues with urinary incontinence for various reasons. • Option A: The perineum may become irritated by the frequent contact with urine. Approximately 13 million Americans experience urinary incontinence. The prevalence is 50% or greater among residents of nursing facilities. Caregivers report that 53% of the homebound elderly are incontinent. A random sampling of hospitalized elderly patients reports that 11% of patients have persistent urinary incontinence at admission, and 23% at discharge. • Option B: Normal fluid intake is at least 1,500 mL/d and clients often decrease their intake to try to minimize urine leakage. Functional urinary incontinence is the involuntary leakage of urine due to environmental or physical barriers to toileting. This type of incontinence is sometimes referred to as toileting difficulty. • Option C: Antihistamines can cause urinary retention rather than urinary incontinence. The urethra is the tube that takes urine from the bladder out of the body. The problem can also be caused by using drugs such as antihistamines (like Benadryl®), antispasmodics (like Detrol®), and tricyclic antidepressants (like Elavil®) that can change the way the bladder muscle works. • Option D: UTIs can contribute to incontinence. Patients should be asked about medical conditions such as chronic obstructive pulmonary disease and asthma (which can cause cough), heart failure (with related fluid overload and diuresis), neurologic conditions (which may suggest dysregulated bladder innervation), musculoskeletal conditions (which may contribute to toileting barriers), etc. • Option E: A fecal impaction can compress the urethra, which results in sm. amts of urine leakage. Overflow urinary incontinence is the involuntary leakage of urine from an overdistended bladder due to impaired detrusor contractility and/or bladder outlet obstruction. Neurologic diseases such as spinal cord injuries, multiple sclerosis, and diabetes can impair detrusor function. Bladder outlet obstruction can be caused by external compression by abdominal or pelvic masses and pelvic organ prolapse, among other causes. A common cause in men is benign prostatic hyperplasia. 23. 23. Question Which action represents the appropriate nursing management of a client wearing a condom catheter? • A. Ensure that the tip of the penis fits snugly against the end of the condom. • B. Check the penis for adequate circulation 30 min after applying. • C. Change the condom every 8 hours. • D. Tape the collecting tube to the lower abdomen. Incorrect Correct Answer: B. Check the penis for adequate circulation 30 min after applying The penis and condom should be checked 1/2 hour after application to ensure that it’s not too tight. and the tubing is taped to the leg or attached to a leg bag. Condom catheters are external urinary catheters that are worn like a condom. They collect urine as it drains out of your bladder and send it to a collection bag strapped to your leg. They’re typically used by men who have urinary incontinence (can’t control their bladder). • Option A: A 1 in. space should be left between the penis and the end of the condom. Place the condom over the tip of the penis and slowly unroll it until it gets to the base. Leave enough room at the tip (1 to 2 inches) so it won’t rub against the condom. • Option C: The condom is changed every 24h. Condom catheters should be replaced every 24 hours. Throw away the old one unless it’s designed to be reusable. The collection bag should be emptied when it’s about half full or at least every three to four hours for a small bag and every eight hours for a large one. • Option D: An indwelling catheter is taped to the lower abdomen or upper thigh. Use a nonadhesive condom catheter to help prevent irritation from adhesive. An inflatable ring holds it in place. Keep the bag lower than the bladder to avoid backflow of urine from the bag. Securely attach the tube to the leg (below the knee, such as the calf), but leave a little slack so it doesn’t pull on the catheter. 24. 24. Question The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? • A. Leaves the catheter in place and gets a new sterile catheter. • B. Leaves the catheter in place and asks another nurse to attempt the procedure. • C. Removes the catheter and redirects it to the urinary meatus. • D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus. Incorrect Correct Answer: A. Leaves the catheter in place and gets a new sterile catheter. The catheter in the vagina is contaminated and can’t be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn’t indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus. Urinary bladder catheterization is performed for both therapeutic and diagnostic purposes. Based on the dwell time, the urinary catheter can be either intermittent (short-term) or indwelling (long-term). • Option B: After exposing the urethral meatus, a lubricated catheter tip is advanced in the meatus until there is a spontaneous return of urine. The catheter balloon is then inflated as per the manufacturer’s recommendations. • Option C: In the event a catheter is inserted in the vagina, it should be left there until a new sterile catheter is successfully inserted into the meatus. Analgesia is of no proven clinical use in women. Lubrication jelly should be applied to the tip of the catheter. The application of lubricant to the urethral meatus is associated with difficulty in catheter insertion. • Option D: Urinary tract infection (UTI) is the most common complication that occurs as a result of long-term catheterization. The normal urinary flow prevents the ascension of microbes from the periurethral skin avoiding the infection. Alteration of the defensive mechanism from the catheter results in an increased risk of UTIs. Escherichia coli and Klebsiella pneumonia are the most common organisms implicated in UTIs. Recurrent UTIs are associated with increased antibiotic resistance. 25. 25. Question Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter? • A. "I will keep the collecting bag below the level of the bladder at all times." • B. "Intake of cranberry juice may help decrease the risk of infection." • C. "Soaking in a warm tub bath may ease the irritation associated with the catheter." • D. "I should use clean tech. when emptying the collecting bag." Incorrect Correct Answer: C. “Soaking in a warm tub bath may ease the irritation associated with the catheter” Soaking in a bathtub can increase the risk of exposure to bacteria. Avoid taking baths, but shower daily. For the first few days after getting a suprapubic catheter, use a waterproof bandage when showering. Once the wound heals, the client can shower as usual, but avoid scented soaps. • Option A: The bag should be below the level of the bladder to promote proper drainage. Always keep the bag below the waist. Check the tube once in a while for bends or kinks that keep pee from flowing out. Don’t use any lotions or powders around where the catheter goes into the body. • Option B: Intake of cranberry juice creates an environment nonconducive to infection. “Indwelling” means inside the body. This catheter drains urine from the bladder into a bag outside the body. Common reasons to have an indwelling catheter are urinary incontinence (leakage), urinary retention (not being able to urinate), a surgery that made this catheter necessary, or another health problem. • Option D: Clean technique is appropriate for touching the exterior portions of the system. Wash hands with soap and water. Empty urine from the bag into the toilet. Pinch the catheter closed between the fingers. Remove the bag. Wipe the end of the catheter with a fresh alcohol pad. Wipe the tip of the new bag with the second alcohol pad. Connect the new bag and stop pinching the catheter now. Make sure there are no bends or kinks in the catheter tube. Wash hands again. 26. 26. Question During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? • A. Stress urinary incontinence • B. Reflex urinary incontinence • C. Functional urinary incontinence • D. Urge urinary incontinence Incorrect Correct Answer: D. Urge urinary incontinence The key phrase is “the urge to void” option one occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. If one feels a strong urge to urinate even when the bladder isn’t full, the incontinence might be related to overactive bladder, sometimes called urge incontinence. This condition occurs in both men and women and involves an overwhelming urge to urinate immediately, frequently followed by loss of urine before the client can reach a bathroom. Even if one never has an accident, urgency and urinary frequency can interfere with work and a social life because of the need to keep running to the bathroom. • Option A: Stress Urinary Incontinence (SUI) is when urine leaks out with sudden pressure on the bladder and urethra, causing the sphincter muscles to open briefly. With mild SUI, pressure may be from sudden forceful activities, like exercise, sneezing, laughing, or coughing. • Option B: Reflex urinary incontinence occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Reflex incontinence occurs when the bladder muscle contracts and urine leaks (often in large amounts) without any warning or urge. This can happen as a result of damage to the nerves that normally warn the brain that the bladder is filling. • Option C: Functional urinary continence is the involuntary loss of urine related to impaired function. If the urinary tract is functioning properly but other illnesses or disabilities are preventing one from staying dry, the client might have what is known as functional incontinence. For example, if an illness rendered the client unaware or unconcerned about the need to find a toilet, the client would become incontinent. Medications, dementia, or mental illness can decrease awareness of the need to find a toilet. 27. 27. Question A female client has a urinary tract infection. Which teaching points by the nurse should be helpful to the client? Select all that apply. • A. Limit fluids to avoid the burning sensation on urination. • B. Review symptoms of UTI with the client. • C. Wipe the perineal area from back to front. • D. Wear cotton underclothes. • E. Take baths rather than showers. Incorrect Correct Answer: B, D Uncomplicated urinary tract infection (UTI) is a bacterial infection of the bladder and associated structures. These are patients with no structural abnormality and no comorbidities, such as diabetes, immunocompromised, or pregnant. Uncomplicated UTI is also known as cystitis or lower UTI. Forty percent of women in the United States will develop a UTI during their lifetime, making it one of the most common infections in women. UTI is uncommon in circumcised males, and by definition, any male UTI is considered complicated. • Option A: Increased fluids decrease concentration and irritation. An uncomplicated UTI usually only involves the bladder. When the bacteria invade the bladder mucosal wall, cystitis is produced. The majority of organisms causing a UTI are enteric coliforms that usually inhabit the periurethral vaginal introitus. These organisms ascend into the bladder and cause a UTI. • Option B: Reviewing the symptoms of UTI with the client validates the diagnosis. Symptoms of uncomplicated UTI are pain on urination (dysuria), frequent urination (frequency), inability to start the urine stream (hesitation), sudden onset of the need to urinate (urgency), and blood in the urine (hematuria). Usually, patients with uncomplicated UTI do not have fever, chills, nausea, vomiting, or back pain, which are signs of kidney involvement or upper tract disease/pyelonephritis. • Option C: The client should wipe the perineal area from front to back to prevent the spread of bacteria from the rectal area to the urethra. Sexual intercourse is a common cause of a UTI as it promotes the migration of bacteria into the bladder. People who frequently void and empty the bladder have a much lower risk of a UTI. • Option D: Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth. Urine is an ideal medium for bacterial growth; factors that make it unfavorable for bacterial growth include a pH of less than 5, presence of organic acids, and high levels of urea. Frequent urination is also known to decrease the risk of UTI. • Option E: Showers reduce exposure of the area to bacteria. Bacteria that cause UTI have adhesins on their surface which allow the organism to attach to the mucosal surface. In addition, a short urethra also makes it easier for the uropathogen to invade the urinary tract. 28. 28. Question The nurse will need to assess the client’s performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion? • A. Ileal conduit • B. Kock pouch • C. Neobladder • D. Vesicostomy Incorrect Correct Answer: B. Kock pouch The ileal conduit and vesicostomy are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. In this new operation, a pouch or reservoir is fashioned out of the terminal ileum with a valve mechanism at its exit to the skin surface. This allows storage of the liquid bowel contents in an expandable container with no leakage of stool or gas and therefore no skin problems. There is no need for appliances or bags, no embarrassment from the involuntary noise and smell of flatus through the ileostomy. The stoma is created flush and within the bikini line. The patient catheterizes the pouch on an average of three times a day. • Option A: An ileal conduit aims to divert urine produced from the upper urinary tracts to a newly formed reservoir created from the terminal ileum. The ureters are disconnected from the bladder and implanted into the conduit. • Option C: Clients with a neobladder can control their voiding. During neobladder surgery, the surgeon takes out the existing bladder and forms an internal pouch from part of the intestine. The pouch, called a neobladder, stores the urine. • Option D: A vesicostomy is a stoma (opening) created between the bladder and the abdomen. This allows urine to drain freely, with low pressure, to help protect and prevent harm to the kidneys. It is a surgical procedure that typically involves an overnight stay in the hospital. 29. 29. Question Which focus is the nurse most likely to teach for a client with a flaccid bladder? • A. Habit training: attempt voiding at specific time periods. • B. Bladder training: delay voiding according to a pre-schedule timetable. • C. Crede's maneuver: apply gentle manual pressure to the lower abdomen. • D. Kegel exercises: contract the pelvic muscles. Incorrect Correct Answer: C. Crede’s maneuver: apply gentle manual pressure to the lower abdomen. Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination, the process is initiated manually. The Credé maneuver is a technique used to void urine from the bladder of an individual who, due to disease, cannot do so without aid. The Credé maneuver is executed by exerting manual pressure on the abdomen at the location of the bladder, just below the navel. Options one, two, and four: to promote continence bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles. • Option A: One type of toilet training is habit training. Habit training is the process of teaching a child to eliminate on the toilet at routine times. Habit training involves teaching children to eliminate on the toilet by developing a toileting routine/habit. • Option B: Bladder training is an important form of behavior therapy that can be effective in treating urinary incontinence. The goals are to increase the amount of time between emptying your bladder and the amount of fluids your bladder can hold. It also can diminish leakage and the sense of urgency associated with the problem. • Option D: Kegel exercises can help make the muscles under the uterus, bladder, and bowel (large intestine) stronger. They can help both men and women who have problems with urine leakage or bowel control. 30. 30. Question Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. • A. Voids each time there is an urge. • B. Practices slow, deep breathing until the urge decreases. • C. Uses adult diapers, for "just in case". • D. Drinks citrus juices and carbonated beverages. • E. Performs pelvic muscle exercises. Incorrect Correct Answer: B, E It is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Bladder training, a program of urinating on schedule, enables the client to gradually increase the amount of urine the client can comfortably hold. Bladder training is a mainstay of treatment for urinary frequency and overactive bladder in both women and men, alone or in conjunction with medications or other techniques. • Option A: Choose an interval. Based on the typical interval between urinations, select a starting interval for training that is 15 minutes longer. If the typical interval is one hour, make a starting interval one hour and 15 minutes. • Option B: When the client starts training, he should empty his bladder first thing in the morning and not again until the interval he set. If the time arrives before he can feel the urge, he should go anyway. If the urge hits first, he should remind himself that his bladder isn’t really full, and use whatever techniques he can to delay going. • Option C: Some clients may need diapers; this is not the best indicator of a successful program. • Option D: Citrus juices may irritate the bladder. Carbonated beverages increase diuresis and the risk of incontinence. • Option E: Try the pelvic floor exercises sometimes called Kegels, or simply try to wait another five minutes before walking slowly to the bathroom. Once comfortable with a set interval, increase it by 15 minutes. Over several weeks or months, the client may find that they are able to wait much longer and that they have experienced far fewer feelings of urgency or episodes of urge incontinence. 31. 31. Question A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation? • A. Coughing • B. Mobility deficits • C. Prostate enlargement • D. Urinary tract infection Incorrect Correct Answer: C. Prostate enlargement An enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25-60mL) of urine to escape (overflow incontinence). Men who are unable to completely empty their bladder and experience unexpected urine leakage may have what is called overflow incontinence. • Option A: Coughing, which raises the intra abdominal pressure, is related to stress incontinence, not overflow incontinence. An enlarged prostate can interfere with the passage of urine through the urethra, the tube connected to the bladder. • Option B: Mobility deficits, such as spinal cord injuries, are related to reflex incontinence, not overflow incontinence. Damage to nerves near the bladder causing under-activity. This can occur with neurological injury or with diseases such as diabetes. • Option D: Urinary tract infections are related to urge incontinence, not overflow incontinence. Men with this type of urinary incontinence often do not feel that their bladders are full, which then leads to leakage as the bladder has reached its full capacity. In addition to leakage, urine left in the bladder can lead to urinary tract infections due to the growth of bacteria as well as bladder stones. 32. 32. Question A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter? • A. Urinal • B. Graduate • C. Large syringe • D. Urine collection bag Incorrect Correct Answer: B. Graduate A graduate is a collection container with volume markings usually at 25 mL increments that promote accurate measurements of urine volume. To measure urine output in critical care units, a Foley catheter is introduced through the patient’s urethra until it reaches his/her bladder. The other end of the catheter is connected to a graduated container that collects the urine. • Option A: Although urinals have volume markings on the side, usually they occur in 100 mL increments that do not promote accurate measurements. Urine output is the best indicator of the state of the patient’s kidneys. If the kidneys are producing an adequate amount of urine it means that they are well perfused and oxygenated. Otherwise, it is a sign that the patient is suffering from some complications. • Option C: Large syringe is impractical. A large syringe is used to obtain a sterile specimen from a retention catheter (Foley catheter). Urine output is required for calculating the patient’s water balance, which is essential in th