2024 NUR 207 FINAL EXAM
WITH CORRECT ANSWERS
A patient will attempt oral feedings for the first time after having a stroke.
The nurse should
assess the gag reflex and then
a. order a varied pureed diet. c. assist the patient into a chair.
b. assess the patient's appetite. d. offer the patient a sip of juice. - CORRECT
ANSWERS-ANS: C
The patient should be as upright as possible before attempting feeding to
make swallowing
easier and decrease aspiration risk. To assess swallowing ability, the nurse
should initially
offer water or ice to the patient. Pureed diets are not recommended because
the texture is too
smooth. The patient may have a poor appetite, but the oral feeding should
be attempted.
DIF: Cognitive Level: Apply (application) REF: 1360
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
To assess whether there is any improvement in a patient's dysuria, which
question will the
nurse ask?
a. "Do you have to urinate at night?"
b. "Do you have blood in your urine?"
c. "Do you have to urinate frequently?"
d. "Do you have pain when you urinate?" - CORRECT ANSWERS-ANS: D
Dysuria is painful urination. The alternate responses are used to assess other
urinary tract
symptoms: hematuria, nocturia, and frequency.
DIF: Cognitive Level: Understand (comprehension) REF: 1025
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
When a patient's urine dipstick test indicates a small amount of protein, the
nurse's next action should be to
a. send a urine specimen to the laboratory to test for ketones.
b. obtain a clean-catch urine for culture and sensitivity testing.
c. inquire about which medications the patient is currently taking.
d. ask the patient about any family history of chronic renal failure. -
CORRECT ANSWERS-ANS: C
,Normally the urinalysis will show zero to trace amounts of protein, but some
medications may give false-positive readings. The other actions by the nurse
may be appropriate, but checking for medications that may affect the
dipstick accuracy should be done first.
DIF: Cognitive Level: Analyze (analysis) REF: 1026
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A hospitalized patient with possible renal insufficiency after coronary artery
bypass surgery is scheduled for a creatinine clearance test. Which item will
the nurse need to obtain?
a. Urinary catheter c. Cleansing towelettes
b. Sterile specimen cup d. Large urine container - CORRECT ANSWERS-ANS:
D
Because creatinine clearance testing involves a 24-hour urine specimen, the
nurse should
obtain a large container for the urine collection. Catheterization, cleaning of
the perineum
with antiseptic towelettes, and a sterile specimen cup are not needed for this
test.
DIF: Cognitive Level: Understand (comprehension) REF: 1031
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A young adult who is employed as a hairdresser and has a 15 pack-year
history of cigarette
smoking is scheduled for an annual physical examination. The nurse will plan
to teach the
patient about the increased risk for
a. renal failure. c. pyelonephritis.
b. kidney stones. d. bladder cancer. - CORRECT ANSWERS-ANS: D
Exposure to the chemicals involved with working as a hairdresser and in
smoking both
increase the risk of bladder cancer, and the nurse should assess whether the
patient
understands this risk. The patient is not at increased risk for renal failure,
pyelonephritis, or
kidney stones.
DIF: Cognitive Level: Apply (application) REF: 1021
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and
Maintenance
Which medication taken at home by a patient with decreased renal function
will be of most concern to the nurse?
a. ibuprofen (Motrin) c. folic acid (vitamin B9)
b. warfarin (Coumadin) d. penicillin (Bicillin C-R) - CORRECT ANSWERS-ANS: A
,The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and
should be
avoided in patients with impaired renal function. The nurse should also ask
about reasons the
patient is taking the other medications, but the medication of most concern
is the ibuprofen.
DIF: Cognitive Level: Analyze (analysis) REF: 1020
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A 79-yr-old patient has been admitted with benign prostatic hyperplasia.
What is most
appropriate to include in the nursing plan of care?
a. Limit fluid intake to no more than 1000 mL/day.
b. Leave a light on in the bathroom during the night.
c. Ask the patient to use a urinal so that urine can be measured.
d. Pad the patient's bed to accommodate overflow incontinence. - CORRECT
ANSWERS-ANS: B
The patient's age and diagnosis indicate a likelihood of nocturia, so leaving
the light on in the
bathroom is appropriate. Fluids should be encouraged because dehydration
is more common
in older patients. The information in the question does not indicate that
measurement of the
patient's output is necessary or that the patient has overflow incontinence.
DIF: Cognitive Level: Analyze (analysis) REF: 1022
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse completing a physical assessment for a newly admitted patient is
unable to feel
either kidney on palpation. Which action should the nurse take?
a. Obtain a urine specimen to check for hematuria.
b. Document the information on the assessment form.
c. Ask the patient about any history of recent sore throat.
d. Ask the health care provider about scheduling a renal ultrasound. -
CORRECT ANSWERS-ANS: B
The kidneys are protected by the abdominal organs, ribs, and muscles of the
back and may not
be palpable under normal circumstances, so no action except to document
the assessment
information is needed. Asking about a recent sore throat, checking for
hematuria, or obtaining
a renal ultrasound may be appropriate when assessing for renal problems for
some patients,
but there is nothing in the question stem to indicate that they are
appropriate for this patient.
, DIF: Cognitive Level: Apply (application) REF: 1023
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
How will the nurse assess for flank tenderness in a patient with suspected
pyelonephritis?
a. Palpate along both sides of the lumbar vertebral column.
b. Strike a flat hand covering the costovertebral angle (CVA).
c. Push fingers upward into the two lowest intercostal spaces.
d. Percuss between the iliac crest and ribs at the midaxillary line. - CORRECT
ANSWERS-ANS: B
Checking for flank pain is best performed by percussion of the CVA and
asking about pain. The other techniques would not assess for flank pain.
DIF: Cognitive Level: Understand (comprehension) REF: 1023
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-
old patient with a creatinine clearance result of 60 mL/min?
a. 60 mL/min c. 120 mL/min
b. 90 mL/min d. 180 mL/min - CORRECT ANSWERS-ANS: A
The creatinine clearance approximates the GFR. The other responses are not
accurate.
DIF: Cognitive Level: Understand (comprehension) REF: 1025
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse assessing the urinary system of a 45-yr-old patient would use
palpation to
a. determine kidney function.
c. check for ureteral peristalsis.
b. identify renal artery bruits.
d. assess for bladder distention. - CORRECT ANSWERS-ANS: D
A distended bladder may be palpable above the symphysis pubis. Palpation
would not be helpful in assessing for the other listed urinary tract
information.
DIF: Cognitive Level: Understand (comprehension) REF: 1023
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient gives the admitting nurse health information before a scheduled
intravenous
pyelogram (IVP). Which item requires the nurse to intervene before the
procedure?
a. The patient has not had food or drink for 8 hours.
b. The patient lists allergies to shellfish and penicillin.
c. The patient complains of costovertebral angle (CVA) tenderness.
d. The patient used a bisacodyl (Dulcolax) tablet the previous night. -
CORRECT ANSWERS-ANS: B
WITH CORRECT ANSWERS
A patient will attempt oral feedings for the first time after having a stroke.
The nurse should
assess the gag reflex and then
a. order a varied pureed diet. c. assist the patient into a chair.
b. assess the patient's appetite. d. offer the patient a sip of juice. - CORRECT
ANSWERS-ANS: C
The patient should be as upright as possible before attempting feeding to
make swallowing
easier and decrease aspiration risk. To assess swallowing ability, the nurse
should initially
offer water or ice to the patient. Pureed diets are not recommended because
the texture is too
smooth. The patient may have a poor appetite, but the oral feeding should
be attempted.
DIF: Cognitive Level: Apply (application) REF: 1360
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
To assess whether there is any improvement in a patient's dysuria, which
question will the
nurse ask?
a. "Do you have to urinate at night?"
b. "Do you have blood in your urine?"
c. "Do you have to urinate frequently?"
d. "Do you have pain when you urinate?" - CORRECT ANSWERS-ANS: D
Dysuria is painful urination. The alternate responses are used to assess other
urinary tract
symptoms: hematuria, nocturia, and frequency.
DIF: Cognitive Level: Understand (comprehension) REF: 1025
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
When a patient's urine dipstick test indicates a small amount of protein, the
nurse's next action should be to
a. send a urine specimen to the laboratory to test for ketones.
b. obtain a clean-catch urine for culture and sensitivity testing.
c. inquire about which medications the patient is currently taking.
d. ask the patient about any family history of chronic renal failure. -
CORRECT ANSWERS-ANS: C
,Normally the urinalysis will show zero to trace amounts of protein, but some
medications may give false-positive readings. The other actions by the nurse
may be appropriate, but checking for medications that may affect the
dipstick accuracy should be done first.
DIF: Cognitive Level: Analyze (analysis) REF: 1026
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A hospitalized patient with possible renal insufficiency after coronary artery
bypass surgery is scheduled for a creatinine clearance test. Which item will
the nurse need to obtain?
a. Urinary catheter c. Cleansing towelettes
b. Sterile specimen cup d. Large urine container - CORRECT ANSWERS-ANS:
D
Because creatinine clearance testing involves a 24-hour urine specimen, the
nurse should
obtain a large container for the urine collection. Catheterization, cleaning of
the perineum
with antiseptic towelettes, and a sterile specimen cup are not needed for this
test.
DIF: Cognitive Level: Understand (comprehension) REF: 1031
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A young adult who is employed as a hairdresser and has a 15 pack-year
history of cigarette
smoking is scheduled for an annual physical examination. The nurse will plan
to teach the
patient about the increased risk for
a. renal failure. c. pyelonephritis.
b. kidney stones. d. bladder cancer. - CORRECT ANSWERS-ANS: D
Exposure to the chemicals involved with working as a hairdresser and in
smoking both
increase the risk of bladder cancer, and the nurse should assess whether the
patient
understands this risk. The patient is not at increased risk for renal failure,
pyelonephritis, or
kidney stones.
DIF: Cognitive Level: Apply (application) REF: 1021
TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and
Maintenance
Which medication taken at home by a patient with decreased renal function
will be of most concern to the nurse?
a. ibuprofen (Motrin) c. folic acid (vitamin B9)
b. warfarin (Coumadin) d. penicillin (Bicillin C-R) - CORRECT ANSWERS-ANS: A
,The nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and
should be
avoided in patients with impaired renal function. The nurse should also ask
about reasons the
patient is taking the other medications, but the medication of most concern
is the ibuprofen.
DIF: Cognitive Level: Analyze (analysis) REF: 1020
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A 79-yr-old patient has been admitted with benign prostatic hyperplasia.
What is most
appropriate to include in the nursing plan of care?
a. Limit fluid intake to no more than 1000 mL/day.
b. Leave a light on in the bathroom during the night.
c. Ask the patient to use a urinal so that urine can be measured.
d. Pad the patient's bed to accommodate overflow incontinence. - CORRECT
ANSWERS-ANS: B
The patient's age and diagnosis indicate a likelihood of nocturia, so leaving
the light on in the
bathroom is appropriate. Fluids should be encouraged because dehydration
is more common
in older patients. The information in the question does not indicate that
measurement of the
patient's output is necessary or that the patient has overflow incontinence.
DIF: Cognitive Level: Analyze (analysis) REF: 1022
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity
The nurse completing a physical assessment for a newly admitted patient is
unable to feel
either kidney on palpation. Which action should the nurse take?
a. Obtain a urine specimen to check for hematuria.
b. Document the information on the assessment form.
c. Ask the patient about any history of recent sore throat.
d. Ask the health care provider about scheduling a renal ultrasound. -
CORRECT ANSWERS-ANS: B
The kidneys are protected by the abdominal organs, ribs, and muscles of the
back and may not
be palpable under normal circumstances, so no action except to document
the assessment
information is needed. Asking about a recent sore throat, checking for
hematuria, or obtaining
a renal ultrasound may be appropriate when assessing for renal problems for
some patients,
but there is nothing in the question stem to indicate that they are
appropriate for this patient.
, DIF: Cognitive Level: Apply (application) REF: 1023
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
How will the nurse assess for flank tenderness in a patient with suspected
pyelonephritis?
a. Palpate along both sides of the lumbar vertebral column.
b. Strike a flat hand covering the costovertebral angle (CVA).
c. Push fingers upward into the two lowest intercostal spaces.
d. Percuss between the iliac crest and ribs at the midaxillary line. - CORRECT
ANSWERS-ANS: B
Checking for flank pain is best performed by percussion of the CVA and
asking about pain. The other techniques would not assess for flank pain.
DIF: Cognitive Level: Understand (comprehension) REF: 1023
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-
old patient with a creatinine clearance result of 60 mL/min?
a. 60 mL/min c. 120 mL/min
b. 90 mL/min d. 180 mL/min - CORRECT ANSWERS-ANS: A
The creatinine clearance approximates the GFR. The other responses are not
accurate.
DIF: Cognitive Level: Understand (comprehension) REF: 1025
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
The nurse assessing the urinary system of a 45-yr-old patient would use
palpation to
a. determine kidney function.
c. check for ureteral peristalsis.
b. identify renal artery bruits.
d. assess for bladder distention. - CORRECT ANSWERS-ANS: D
A distended bladder may be palpable above the symphysis pubis. Palpation
would not be helpful in assessing for the other listed urinary tract
information.
DIF: Cognitive Level: Understand (comprehension) REF: 1023
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
A patient gives the admitting nurse health information before a scheduled
intravenous
pyelogram (IVP). Which item requires the nurse to intervene before the
procedure?
a. The patient has not had food or drink for 8 hours.
b. The patient lists allergies to shellfish and penicillin.
c. The patient complains of costovertebral angle (CVA) tenderness.
d. The patient used a bisacodyl (Dulcolax) tablet the previous night. -
CORRECT ANSWERS-ANS: B
