170 EXAM 3 STUDY SET QUESTIONS
AND ANSWERS GRADED A+.
1. There is a 24-hr urine collection in process for a client. The nursing assistive personnel (NAP)
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.
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 knows that the results of a fecal occult blood test can be inaccurate if
1.The client has had an excessive intake of red meat.
2.The female client is menstruating
,3.The client takes high doses of vitamin C
4.All of the above - Answer 4.All of the above
Rationale: The results of a fecal occult blood test can be inaccurate for any of the reasons given.
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 her plan of care?
1.Diarrhea
2.Constipation
3.Risk for Ineffective Therapeutic Regimen
4.Perceived Constipation - Answer 4.Perceived Constipation
Rationale: 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
1.Introducing air into the colon
2.Leaking the solution around the stoma
3.Administering the solution too rapidly
4.Introduction of bacteria from the stoma - Answer 2.Leaking the solution around the stoma
Rationale: 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 her ostomy. The client states, "Oh, this is so disgusting. I'll
never be able to touch this thing." The nurse's best response is
,1."I'm sure you will get used to taking care of it eventually."
2."Yes, it is pretty messy, so I'll take care of it for you today."
3."It sounds like you are really upset."
4."You sound very angry. Should I call the chaplain for you?" - Answer 3."It sounds like you are really
upset."
Rationale: This statement reflects the principles of therapeutic communication.
In meeting the safety needs of the adolescent client, it would be most important for the nurse to focus
his or her teaching on
1.Smoking cessation
2.Sports injuries
3.Alcohol abuse
4.Driver's education - Answer 4.Driver's education
Rationale: The leading cause of death for adolescents is motor vehicle accidents.
A child has had hiccups for 2 hr. Is this a sign of suspected ingestion of poison?
1.Yes
2.No - Answer 2.No
Rationale: Hiccups are not a sign of suspected ingestion of poison.
When implementing the use of restraints on a hospitalized client, the nurse should
1.Restrain all confused clients so that they do not sustain a fall injury.
, 2.Tie the restraint to the bottom of the siderail so the client cannot reach it.
3.Ensure that the primary care provider renews the order for restraints once every 24 hr.
4.Release the restraints and provide skin care at least once every shift. - Answer 3.Ensure that the
primary care provider renews the order for restraints once every 24 hr.
Rationale: This statement meets the most current guidelines for the provider's orders related to the use
of restraints.
How would you, as the nurse, support a culture of safety? Select all that apply.
1.Completing incident reports when appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident - Answer 1.Completing incident reports when
appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident
Key components of a culture of safety include:
• Team empowerment: Every individual has the opportunity to be heard, feel important, and be a valued
team member for the contribution offered.
• Communication: Open and honest lines of communication are needed between the team members
and from the team to other hospital units.
• Transparency: Team members are united in their efforts to eliminate rumors and operate with only the
facts, contributing to mutual team goals.
• Accountability: Claim ownership for human error and disclose the error to help prevent similar errors;
when an error is made own it, do not try to cover it up.
The client has a draining abdominal wound that has become infected. In caring for the client, the nurse
will implement
AND ANSWERS GRADED A+.
1. There is a 24-hr urine collection in process for a client. The nursing assistive personnel (NAP)
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.
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 knows that the results of a fecal occult blood test can be inaccurate if
1.The client has had an excessive intake of red meat.
2.The female client is menstruating
,3.The client takes high doses of vitamin C
4.All of the above - Answer 4.All of the above
Rationale: The results of a fecal occult blood test can be inaccurate for any of the reasons given.
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 her plan of care?
1.Diarrhea
2.Constipation
3.Risk for Ineffective Therapeutic Regimen
4.Perceived Constipation - Answer 4.Perceived Constipation
Rationale: 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
1.Introducing air into the colon
2.Leaking the solution around the stoma
3.Administering the solution too rapidly
4.Introduction of bacteria from the stoma - Answer 2.Leaking the solution around the stoma
Rationale: 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 her ostomy. The client states, "Oh, this is so disgusting. I'll
never be able to touch this thing." The nurse's best response is
,1."I'm sure you will get used to taking care of it eventually."
2."Yes, it is pretty messy, so I'll take care of it for you today."
3."It sounds like you are really upset."
4."You sound very angry. Should I call the chaplain for you?" - Answer 3."It sounds like you are really
upset."
Rationale: This statement reflects the principles of therapeutic communication.
In meeting the safety needs of the adolescent client, it would be most important for the nurse to focus
his or her teaching on
1.Smoking cessation
2.Sports injuries
3.Alcohol abuse
4.Driver's education - Answer 4.Driver's education
Rationale: The leading cause of death for adolescents is motor vehicle accidents.
A child has had hiccups for 2 hr. Is this a sign of suspected ingestion of poison?
1.Yes
2.No - Answer 2.No
Rationale: Hiccups are not a sign of suspected ingestion of poison.
When implementing the use of restraints on a hospitalized client, the nurse should
1.Restrain all confused clients so that they do not sustain a fall injury.
, 2.Tie the restraint to the bottom of the siderail so the client cannot reach it.
3.Ensure that the primary care provider renews the order for restraints once every 24 hr.
4.Release the restraints and provide skin care at least once every shift. - Answer 3.Ensure that the
primary care provider renews the order for restraints once every 24 hr.
Rationale: This statement meets the most current guidelines for the provider's orders related to the use
of restraints.
How would you, as the nurse, support a culture of safety? Select all that apply.
1.Completing incident reports when appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident - Answer 1.Completing incident reports when
appropriate
2.Completing incident reports for a near miss
3.Communicating product concerns to an immediate supervisor
4.Identifying the person responsible for an incident
Key components of a culture of safety include:
• Team empowerment: Every individual has the opportunity to be heard, feel important, and be a valued
team member for the contribution offered.
• Communication: Open and honest lines of communication are needed between the team members
and from the team to other hospital units.
• Transparency: Team members are united in their efforts to eliminate rumors and operate with only the
facts, contributing to mutual team goals.
• Accountability: Claim ownership for human error and disclose the error to help prevent similar errors;
when an error is made own it, do not try to cover it up.
The client has a draining abdominal wound that has become infected. In caring for the client, the nurse
will implement
