NURS 336 Final Questions With Complete Solutions
A 53-year-old patient is being treated for hypertension and a
history of thrombophlebitis (blood clots). She comes to the
clinic complaining, "I have to get up all night to go to the
bathroom, and I think my urine looks orange!" What is the
nurse's best response?
"It sounds like you may have a urinary tract infection."
"Your high blood pressure is adversely affecting your kidneys."
"Have you tried to restrict your fluid intake?"
"What medications are you taking and when?" Correct Answers
what meds are you taking and when
The nurse should first assess the patient's medication history
before making any interpretation. The patient may be taking
diuretics before going to bed or taking other medications that
can change the urine's color.
A 65-year-old, 61-kg patient is ready for her annual flu vaccine,
which is delivered intramuscularly. What size needle would the
nurse use to administer this intramuscular (IM) injection in the
deltoid muscle of this patient?
a. 25-gauge, 3/8-inch needle.
b. 25-gauge, 5/8-inch needle.
c. 25-gauge, 1-inch needle.
d. 25-gauge, 2-inch needle. Correct Answers c
A nurse inserting an indwelling urinary catheter in a female
patient advances the catheter and obtains clear yellow urine.
What is the next action the nurse should take?
,Inflate the balloon with the prefilled syringe of sterile water in
the balloon port.
Pull gently back on the catheter approximately 1 inch or until
resistance is met.
Advance catheter another 1 to 2 inches and inflate balloon.
Ask patient to bear down as if to void. Correct Answers
advance
A nurse is explaining the procedure for inserting an indwelling
urinary catheter. Which of the following explanations regarding
anchoring of the catheter would be most accurate?
a. An indwelling catheter tube is secured to a female patient's
abdomen to prevent accidental dislodgment.
b. An indwelling catheter tube is secured to the male patient's
inner thigh with a strip of nonallergenic tape or a commercial
tube holder.
c. It is important to anchor the catheter tubing to minimize the
risk for urethral trauma and bladder spasms from traction and to
prevent accidental dislodgment.
d. When securing the catheter tubing, slack in the catheter
should be avoided to prevent movement and possible tissue
injury. Correct Answers c
A nursing student is assigned to take the vital signs on a patient
and finds the radial pulse to be irregular. What action should the
nursing student take?
Ask a fellow student to assess the pulse.
Auscultate the patient's apical pulse.
Wait 15 minutes and reassess the pulse.
Check the patient's previous pulse reading. Correct Answers
apical
, A patient has a diagnosis of Clostridium difficile. What is most
important for the nurse to convey to the NAP regarding this
patient's care? Correct Answers To wash hands with soap and
water before and after caring for patients with C. difficile.
A patient has a loop colostomy. The patient complains that the
distal stoma looks like it is secreting mucus. What is your best
response?
"The distal stoma may secrete mucus and that would be
normal."
"The distal stoma of a loop colostomy is the functional end that
excretes urine and requires more frequent changing of the
pouch."
"The proximal stoma secretes mucus but otherwise is considered
nonfunctional. The output from the distal stoma is called
effluent."
"Let me take a look at your pouch of the distal stoma; perhaps it
is leaking." Correct Answers distal stoma mucus and that
would be normal
A postoperative diabetic patient had an exploratory laparotomy
(incision in the abdomen) 5 days ago. The patient's history
indicates obesity with a body mass index (BMI) of 32 and
smoking 1 pack/day. Based on this information, the nurse
understands the patient should be observed for:
Developing a blood clot.
Developing a fistula.
Wound dehiscence.
Hemorrhage. Correct Answers dehiscence
A 53-year-old patient is being treated for hypertension and a
history of thrombophlebitis (blood clots). She comes to the
clinic complaining, "I have to get up all night to go to the
bathroom, and I think my urine looks orange!" What is the
nurse's best response?
"It sounds like you may have a urinary tract infection."
"Your high blood pressure is adversely affecting your kidneys."
"Have you tried to restrict your fluid intake?"
"What medications are you taking and when?" Correct Answers
what meds are you taking and when
The nurse should first assess the patient's medication history
before making any interpretation. The patient may be taking
diuretics before going to bed or taking other medications that
can change the urine's color.
A 65-year-old, 61-kg patient is ready for her annual flu vaccine,
which is delivered intramuscularly. What size needle would the
nurse use to administer this intramuscular (IM) injection in the
deltoid muscle of this patient?
a. 25-gauge, 3/8-inch needle.
b. 25-gauge, 5/8-inch needle.
c. 25-gauge, 1-inch needle.
d. 25-gauge, 2-inch needle. Correct Answers c
A nurse inserting an indwelling urinary catheter in a female
patient advances the catheter and obtains clear yellow urine.
What is the next action the nurse should take?
,Inflate the balloon with the prefilled syringe of sterile water in
the balloon port.
Pull gently back on the catheter approximately 1 inch or until
resistance is met.
Advance catheter another 1 to 2 inches and inflate balloon.
Ask patient to bear down as if to void. Correct Answers
advance
A nurse is explaining the procedure for inserting an indwelling
urinary catheter. Which of the following explanations regarding
anchoring of the catheter would be most accurate?
a. An indwelling catheter tube is secured to a female patient's
abdomen to prevent accidental dislodgment.
b. An indwelling catheter tube is secured to the male patient's
inner thigh with a strip of nonallergenic tape or a commercial
tube holder.
c. It is important to anchor the catheter tubing to minimize the
risk for urethral trauma and bladder spasms from traction and to
prevent accidental dislodgment.
d. When securing the catheter tubing, slack in the catheter
should be avoided to prevent movement and possible tissue
injury. Correct Answers c
A nursing student is assigned to take the vital signs on a patient
and finds the radial pulse to be irregular. What action should the
nursing student take?
Ask a fellow student to assess the pulse.
Auscultate the patient's apical pulse.
Wait 15 minutes and reassess the pulse.
Check the patient's previous pulse reading. Correct Answers
apical
, A patient has a diagnosis of Clostridium difficile. What is most
important for the nurse to convey to the NAP regarding this
patient's care? Correct Answers To wash hands with soap and
water before and after caring for patients with C. difficile.
A patient has a loop colostomy. The patient complains that the
distal stoma looks like it is secreting mucus. What is your best
response?
"The distal stoma may secrete mucus and that would be
normal."
"The distal stoma of a loop colostomy is the functional end that
excretes urine and requires more frequent changing of the
pouch."
"The proximal stoma secretes mucus but otherwise is considered
nonfunctional. The output from the distal stoma is called
effluent."
"Let me take a look at your pouch of the distal stoma; perhaps it
is leaking." Correct Answers distal stoma mucus and that
would be normal
A postoperative diabetic patient had an exploratory laparotomy
(incision in the abdomen) 5 days ago. The patient's history
indicates obesity with a body mass index (BMI) of 32 and
smoking 1 pack/day. Based on this information, the nurse
understands the patient should be observed for:
Developing a blood clot.
Developing a fistula.
Wound dehiscence.
Hemorrhage. Correct Answers dehiscence
