NUR215 EXAM 4 Exam Questions with
Complete Answers
The female client states to the nurse, "I'm so distressed. It seems like every time I laugh
hard, I wet myself." The nurse knows that this condition is known as:
A .Stress incontinence
B. Urge incontinence
C. Functional incontinence
D. Unconscious incontinence - Answer-A. Stress incontinence
Stress incontinence results from increased pressure within the abdominal cavity.
The nurse prepares to insert an indwelling urinary catheter. Which statement least
explains the reason for this intervention?
A. Empty your bladder prior to your procedure.
B. Treat your problem of leaking urine.
C. Obtain a sterile urine specimen for culture.
D. Measure the amount of urine left after you emptied your bladder. - Answer-B.Treat
your problem of leaking urine.
Insertion of a urinary catheter is not a "treatment" for incontinence.
There is a 24-hr urine collection in process for a client. The unlicensed assistive
personnel (UAP) inadvertently empties one specimen into the toilet instead of the
collection "hat." The nurse should:
A. Continue with the collection of urine until the 24-hr time period is finished.
B. Make a note to the lab to inform them that one specimen was missed during the
collection.
C. Begin filling a new collection container and take both containers to the lab at the end
of the collection period.
D. Dispose of the urine already collected and begin an entirely new 24-hr collection. -
Answer-D. Dispose of the urine already collected and begin an entirely new 24-hr
collection.
Once one specimen is missed during a 24-hr urine collection, the results of the
laboratory test will be inaccurate, and the collection must be restarted.
Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data,
the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years."
Which nursing diagnosis is most appropriate for the nurse to use in their plan of care?
A. Diarrhea
B. Constipation
C. Risk for Ineffective Therapeutic Regimen
D. Perceived Constipation - Answer-D. Perceived Constipation
Daily laxative use by the patient might suggest that she perceives she is constipated,
and the nurse would gather further assessment data related to the client's bowel
pattern. There is not enough data to infer actual constipation.
, You are caring for a patient with a colostomy. In order to provide safe care, you
understand that when irrigating a colostomy a proper fitting cone is needed to prevent:
A. Introducing air into the colon
B. Leaking the solution around the stoma
C. Administering the solution too rapidly
D. Introduction of bacteria from the stoma - Answer-B .Leaking the solution around the
stoma
A proper fitting cone prevents leakage of the solution around the stoma that may cause
irritation and damage to the skin surrounding the stoma.
The nurse is assisting the client in caring for their ostomy. The client states, "Oh, this is
so disgusting. I'll never be able to touch this thing." The nurse's best response is:
A ."I'm sure you will get used to taking care of it eventually."
B. "Yes, it is pretty messy, so I'll take care of it for you today."
C. "It sounds like you are really upset."
D. "You sound very angry. Should I call the chaplain for you?" - Answer-C."It sounds
like you are really upset."
This statement reflects the principles of therapeutic communication.
A patient who is obese is admitted with a diagnosis of congestive heart failure. The
nursing history reveals the patient has diabetes, smokes 2 packs of cigarettes daily, and
is noncompliant with diet, exercise, and medications. The student nurse assigned to the
patient states, "Let's focus on making them compliant, which will solve all the problems.
Otherwise, we can't help them." What is the most appropriate response?
A ."Let's explore reasons for the noncompliance."
B. "This statement shows a bias against the patient."
C. "Let's discuss how you derived your priority of care."
D. "What do you know about congestive heart failure?" - Answer-
On assessment of a patient with acute renal failure, the nurse finds the following:
distended neck veins, cool and pale skin, and crackles in the lungs. The nurse should
suspect the patient is experiencing:
A. Hypocalcemia
B. Hypovolemia
C. Hypervolemia
D. Hypercalcemia - Answer-C. Hypervolemia
This patient is showing signs of fluid overload, or hypervolemia. Other findings include
elevated blood pressure, bounding pulse, and increased respirations due to increased
intravascular volume.
The nurse is administering a blood transfusion to a patient in shock. After 30 min the
patient spikes a fever and reports chest pain. Their blood pressure falls suddenly and
they become tachycardic. What type of reaction is this patient experiencing?
A .Allergic
B. Febrile
Complete Answers
The female client states to the nurse, "I'm so distressed. It seems like every time I laugh
hard, I wet myself." The nurse knows that this condition is known as:
A .Stress incontinence
B. Urge incontinence
C. Functional incontinence
D. Unconscious incontinence - Answer-A. Stress incontinence
Stress incontinence results from increased pressure within the abdominal cavity.
The nurse prepares to insert an indwelling urinary catheter. Which statement least
explains the reason for this intervention?
A. Empty your bladder prior to your procedure.
B. Treat your problem of leaking urine.
C. Obtain a sterile urine specimen for culture.
D. Measure the amount of urine left after you emptied your bladder. - Answer-B.Treat
your problem of leaking urine.
Insertion of a urinary catheter is not a "treatment" for incontinence.
There is a 24-hr urine collection in process for a client. The unlicensed assistive
personnel (UAP) inadvertently empties one specimen into the toilet instead of the
collection "hat." The nurse should:
A. Continue with the collection of urine until the 24-hr time period is finished.
B. Make a note to the lab to inform them that one specimen was missed during the
collection.
C. Begin filling a new collection container and take both containers to the lab at the end
of the collection period.
D. Dispose of the urine already collected and begin an entirely new 24-hr collection. -
Answer-D. Dispose of the urine already collected and begin an entirely new 24-hr
collection.
Once one specimen is missed during a 24-hr urine collection, the results of the
laboratory test will be inaccurate, and the collection must be restarted.
Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data,
the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years."
Which nursing diagnosis is most appropriate for the nurse to use in their plan of care?
A. Diarrhea
B. Constipation
C. Risk for Ineffective Therapeutic Regimen
D. Perceived Constipation - Answer-D. Perceived Constipation
Daily laxative use by the patient might suggest that she perceives she is constipated,
and the nurse would gather further assessment data related to the client's bowel
pattern. There is not enough data to infer actual constipation.
, You are caring for a patient with a colostomy. In order to provide safe care, you
understand that when irrigating a colostomy a proper fitting cone is needed to prevent:
A. Introducing air into the colon
B. Leaking the solution around the stoma
C. Administering the solution too rapidly
D. Introduction of bacteria from the stoma - Answer-B .Leaking the solution around the
stoma
A proper fitting cone prevents leakage of the solution around the stoma that may cause
irritation and damage to the skin surrounding the stoma.
The nurse is assisting the client in caring for their ostomy. The client states, "Oh, this is
so disgusting. I'll never be able to touch this thing." The nurse's best response is:
A ."I'm sure you will get used to taking care of it eventually."
B. "Yes, it is pretty messy, so I'll take care of it for you today."
C. "It sounds like you are really upset."
D. "You sound very angry. Should I call the chaplain for you?" - Answer-C."It sounds
like you are really upset."
This statement reflects the principles of therapeutic communication.
A patient who is obese is admitted with a diagnosis of congestive heart failure. The
nursing history reveals the patient has diabetes, smokes 2 packs of cigarettes daily, and
is noncompliant with diet, exercise, and medications. The student nurse assigned to the
patient states, "Let's focus on making them compliant, which will solve all the problems.
Otherwise, we can't help them." What is the most appropriate response?
A ."Let's explore reasons for the noncompliance."
B. "This statement shows a bias against the patient."
C. "Let's discuss how you derived your priority of care."
D. "What do you know about congestive heart failure?" - Answer-
On assessment of a patient with acute renal failure, the nurse finds the following:
distended neck veins, cool and pale skin, and crackles in the lungs. The nurse should
suspect the patient is experiencing:
A. Hypocalcemia
B. Hypovolemia
C. Hypervolemia
D. Hypercalcemia - Answer-C. Hypervolemia
This patient is showing signs of fluid overload, or hypervolemia. Other findings include
elevated blood pressure, bounding pulse, and increased respirations due to increased
intravascular volume.
The nurse is administering a blood transfusion to a patient in shock. After 30 min the
patient spikes a fever and reports chest pain. Their blood pressure falls suddenly and
they become tachycardic. What type of reaction is this patient experiencing?
A .Allergic
B. Febrile
