NUR 325 EXAM 2 REVIEW QUESTIONS
Which of the following health conditions would be LEAST likely to cause fluid and
electrolyte imbalances?
a. Vomiting and diarrhea
b. Breaking a leg
c. Renal failure
d. Congestive heart failure (CHF) - Answers :B
The nurse is talking with a patient who was just diagnosed with a urinary tract infection.
The patient asks the nurse how to prevent such infections in the future. The nurse
should make which appropriate recommendations for the patient? (Select all that apply.)
a. Drink 6 to 8 glasses of noncaffeinated fluids daily.
b. Exercise daily.
c. Increase fiber in the diet.
d. Void when the urge is felt.
e. Eat fruit twice daily. - Answers :A D (Drinking noncaffeinated drinks and voiding when
the urge happens are the most appropriate measures for avoiding a urinary tract
infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract
infection.)
When assessing a patient's first voided urine of the day, which finding should be
reported to the health care provider?
a. Pale yellow urine
b. Slightly cloudy urine
c. Light pink urine
d. Dark amber urine - Answers :C (Light pink urine indicates the presence of blood in
the urine, which is never a normal finding. First voided urine can normally be slightly
cloudy and darker in color. Pale yellow urine indicates normal finding.)
What is a critical step when inserting an indwelling catheter into a male patient?
a. Slowly inflate the catheter balloon with sterile saline.
b. Secure the catheter drainage tubing to the bed sheets
c. Advance the catheter to the bifurcation of the drainage and balloon ports.
d. Advance the catheter until urine flows, then insert ¼ inch more. - Answers :C
(Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the
prostatic urethra causing trauma and pain. Catheter balloons are never inflated with
saline. Securing the catheter drainage tubing to the bed sheets increases the risk for
accidental pulling or tension on the catheter. The advancement of the catheter until
flows and then inserting ¼ inch more is not unique to the male patient.)
,Which nursing intervention minimizes the risk for trauma and infection when applying an
external/condom catheter?
a. Leave a gap of 3-5 inches between the tip of the penis and drainage tube
b. Shave the pubic area so that hair does not adhere
c. Wash with soap and water prior to applying the condom type catheter.
d. Apply tape to the condom sheath to keep it securely in place. - Answers :C (Hygiene
minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space between
tip of the glans penis and the end of the catheter. Excess space may cause pooling of
urine causing excessive exposure to urine. Shaving the pubic area increases the risk for
skin irritation. The condom should be secure but not tight. Application of tape is
contraindicated because it could interfere with circulation increasing risk for necrosis of
the penis.)
What instructions should the nurse give the NAP concerning a patient who has had an
indwelling urinary catheter removed that day?
a. Limit oral fluid intake to avoid possible urinary incontinence.
b. Expect patient complaints of suprapubic fullness and discomfort.
c. Report the time and amount of first voiding.
d. Instruct patient to stay in bed and use a urinal or bedpan. - Answers :C (In order to
adequately assess bladder function after a catheter is removed; voiding frequency and
amount should be monitored. Unless contraindicated, fluids should be encouraged. To
promote normal micturition, patients should be placed in as normal a posture for voiding
as possible. Suprapubic tenderness and pain are possible indicators of urinary retention
and/or a UTI.)
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short
term memory and has not been seen toileting independently. What is the best nursing
intervention for this patient?
a. Recommend she be evaluated for an OAB medication.
b. Start a scheduled toileting program.
c. Recommend she be evaluated for an indwelling catheter.
d. Start a bladder retraining program - Answers :B (An appropriate first action would be
to assess the patency of the drainage system. Urine output in the drainage bag should
be more than the volume of the irritant solution infused. If the system is not draining
urine and irritant, the irritant should be stopped immediately, the catheter may be
occluded and the bladder distended.)
Which of the following group of symptoms would trigger you to think there may be some
fluid and electrolyte imbalances in your patient?
a. Tinnitus, erythema, shortness of breath
b. Petechiae, fever, low blood pressure
,c. Unexplained nausea, dizziness, edema
d. Tachycardia, drowsiness, nausea - Answers :C
The patient talks with the nurse about bladder health. What is one of the most important
recommendations the nurse can make for this patient?
a. Eat foods high in fiber.
b. Drink 6 to 8 glasses of noncaffeinated fluids daily.
c. Exercise in the morning and evening.
d. Visit the urologist once yearly. - Answers :B (Drinking 6 to 8 glasses of
noncaffeinated fluids daily helps with bladder health because urine is not stagnating in
the bladder. Exercising and eating foods high in fiber help with bowel elimination but do
not have an effect on urination. Visiting the urologist is good if there is a problem, but
this is not the most important recommendation from the nurse.)
The nurse is caring for a confused patient who is wearing a vest restraint in bed. The
nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows
the unlicensed assistant understands the toileting procedure when making which
statement?
a. The patient must remain in the restraints all day.
b. The patient needs to be toileted to maintain a regular toileting schedule.
c. The patient needs to be provided with adult briefs for incontinence.
d. The patient will use the call bell when he or she feels the urge to void. - Answers :B
(The correct answer is toileting the patient so he or she can maintain a normal toileting
schedule. Leaving the patient in restraints all day is against the standard of care.
Providing the patient with briefs when he or she is not incontinent does not meet the
patient's toileting needs. If the patient is confused, he or she will not be able to use the
call bell.)
If a patient has a colostomy in the area known as the "ascending colon," what would the
nurse expect of the stool in the colostomy device?
a. Stool would be dark.
b. Stool would be formed.
c. Stool would be loose.
d. Stool would have flecks of blood. - Answers :C (The correct answer is C because
stool in the ascending colon is loose or watery. Stool should not be dark or have flecks
of blood. This would be an abnormal finding. Stool would not be loose, because the
colon has not reabsorbed the water yet.)
Which nursing assessment question would best indicate that an incontinent man with a
history of prostate enlargement might not be emptying his bladder adequately?
a. Do you leak urine when you cough or sneeze?
b. Do you need help getting to the toilet?
, c. Do you dribble urine constantly?
d. Does it burn when you pass your urine? - Answers :C (Incontinence characterized by
constant dribbling of urine is associated with incontinence associated with urinary
retention. . The other options point to stress incontinence, functional incontinence or a
UTI.)
The NAP reports to the nurse that a patient's catheter drainage bag has been empty for
4 hours. What is a priority nursing intervention?
a. Implement the "as needed" order to irrigate the catheter.
b. Assess the catheter and drainage tubing for obvious occlusion.
c. Notify the health care provider immediately.
d. Assess the vital signs and intake and output record. - Answers :B (The priority
nursing intervention is to ensure that there is not an occlusion in the catheter or
drainage tubing.)
What nursing intervention decreases the risk for catheter associated urinary tract
infection (CAUTI)?
a. Cleanse the urinary meatus 3-4 times daily with antiseptic solution.
b. Hang the urinary drainage bag below the level with the bladder.
c. Empty the urinary drainage bag daily.
d. Irrigate the urinary catheter with sterile water. - Answers :B (Evidenced based
interventions shown to decrease the risk for CAUTI include ensuring that there is a free
flow of urine from the catheter to the drainage bag.)
What should the nurse teach a young woman with a history of urinary tract infections
about UTI prevention? (Select all that apply.)
a. Keep the bowels regular.
b. Limit water intake to 1-2 glasses a day
c. Wear cotton underwear
d. Cleanse the perineum from front to back.
e. Practice pelvic muscle exercise (Kegel) daily. - Answers :A C D (All are interventions
that lead to healthy bladder habits. Adequate hydration will ensure that the bladder is
regularly flushed out and will help prevent a UTI. Pelvic muscle exercises promote
pelvic health but not necessarily prevent UTI.)
When a patient has fecal incontinence as a result of cognitive impairment, it may be
helpful to teach caregivers to do which of the following interventions?
a. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks
b. Use diapers and heavy padding on the bed
c. Initiate bowel or habit training program to promote continence
Which of the following health conditions would be LEAST likely to cause fluid and
electrolyte imbalances?
a. Vomiting and diarrhea
b. Breaking a leg
c. Renal failure
d. Congestive heart failure (CHF) - Answers :B
The nurse is talking with a patient who was just diagnosed with a urinary tract infection.
The patient asks the nurse how to prevent such infections in the future. The nurse
should make which appropriate recommendations for the patient? (Select all that apply.)
a. Drink 6 to 8 glasses of noncaffeinated fluids daily.
b. Exercise daily.
c. Increase fiber in the diet.
d. Void when the urge is felt.
e. Eat fruit twice daily. - Answers :A D (Drinking noncaffeinated drinks and voiding when
the urge happens are the most appropriate measures for avoiding a urinary tract
infection. Increasing fiber, exercising, and eating fruit do not prevent a urinary tract
infection.)
When assessing a patient's first voided urine of the day, which finding should be
reported to the health care provider?
a. Pale yellow urine
b. Slightly cloudy urine
c. Light pink urine
d. Dark amber urine - Answers :C (Light pink urine indicates the presence of blood in
the urine, which is never a normal finding. First voided urine can normally be slightly
cloudy and darker in color. Pale yellow urine indicates normal finding.)
What is a critical step when inserting an indwelling catheter into a male patient?
a. Slowly inflate the catheter balloon with sterile saline.
b. Secure the catheter drainage tubing to the bed sheets
c. Advance the catheter to the bifurcation of the drainage and balloon ports.
d. Advance the catheter until urine flows, then insert ¼ inch more. - Answers :C
(Advancing the catheter to the bifurcation avoids inflating the catheter balloon in the
prostatic urethra causing trauma and pain. Catheter balloons are never inflated with
saline. Securing the catheter drainage tubing to the bed sheets increases the risk for
accidental pulling or tension on the catheter. The advancement of the catheter until
flows and then inserting ¼ inch more is not unique to the male patient.)
,Which nursing intervention minimizes the risk for trauma and infection when applying an
external/condom catheter?
a. Leave a gap of 3-5 inches between the tip of the penis and drainage tube
b. Shave the pubic area so that hair does not adhere
c. Wash with soap and water prior to applying the condom type catheter.
d. Apply tape to the condom sheath to keep it securely in place. - Answers :C (Hygiene
minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space between
tip of the glans penis and the end of the catheter. Excess space may cause pooling of
urine causing excessive exposure to urine. Shaving the pubic area increases the risk for
skin irritation. The condom should be secure but not tight. Application of tape is
contraindicated because it could interfere with circulation increasing risk for necrosis of
the penis.)
What instructions should the nurse give the NAP concerning a patient who has had an
indwelling urinary catheter removed that day?
a. Limit oral fluid intake to avoid possible urinary incontinence.
b. Expect patient complaints of suprapubic fullness and discomfort.
c. Report the time and amount of first voiding.
d. Instruct patient to stay in bed and use a urinal or bedpan. - Answers :C (In order to
adequately assess bladder function after a catheter is removed; voiding frequency and
amount should be monitored. Unless contraindicated, fluids should be encouraged. To
promote normal micturition, patients should be placed in as normal a posture for voiding
as possible. Suprapubic tenderness and pain are possible indicators of urinary retention
and/or a UTI.)
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short
term memory and has not been seen toileting independently. What is the best nursing
intervention for this patient?
a. Recommend she be evaluated for an OAB medication.
b. Start a scheduled toileting program.
c. Recommend she be evaluated for an indwelling catheter.
d. Start a bladder retraining program - Answers :B (An appropriate first action would be
to assess the patency of the drainage system. Urine output in the drainage bag should
be more than the volume of the irritant solution infused. If the system is not draining
urine and irritant, the irritant should be stopped immediately, the catheter may be
occluded and the bladder distended.)
Which of the following group of symptoms would trigger you to think there may be some
fluid and electrolyte imbalances in your patient?
a. Tinnitus, erythema, shortness of breath
b. Petechiae, fever, low blood pressure
,c. Unexplained nausea, dizziness, edema
d. Tachycardia, drowsiness, nausea - Answers :C
The patient talks with the nurse about bladder health. What is one of the most important
recommendations the nurse can make for this patient?
a. Eat foods high in fiber.
b. Drink 6 to 8 glasses of noncaffeinated fluids daily.
c. Exercise in the morning and evening.
d. Visit the urologist once yearly. - Answers :B (Drinking 6 to 8 glasses of
noncaffeinated fluids daily helps with bladder health because urine is not stagnating in
the bladder. Exercising and eating foods high in fiber help with bowel elimination but do
not have an effect on urination. Visiting the urologist is good if there is a problem, but
this is not the most important recommendation from the nurse.)
The nurse is caring for a confused patient who is wearing a vest restraint in bed. The
nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows
the unlicensed assistant understands the toileting procedure when making which
statement?
a. The patient must remain in the restraints all day.
b. The patient needs to be toileted to maintain a regular toileting schedule.
c. The patient needs to be provided with adult briefs for incontinence.
d. The patient will use the call bell when he or she feels the urge to void. - Answers :B
(The correct answer is toileting the patient so he or she can maintain a normal toileting
schedule. Leaving the patient in restraints all day is against the standard of care.
Providing the patient with briefs when he or she is not incontinent does not meet the
patient's toileting needs. If the patient is confused, he or she will not be able to use the
call bell.)
If a patient has a colostomy in the area known as the "ascending colon," what would the
nurse expect of the stool in the colostomy device?
a. Stool would be dark.
b. Stool would be formed.
c. Stool would be loose.
d. Stool would have flecks of blood. - Answers :C (The correct answer is C because
stool in the ascending colon is loose or watery. Stool should not be dark or have flecks
of blood. This would be an abnormal finding. Stool would not be loose, because the
colon has not reabsorbed the water yet.)
Which nursing assessment question would best indicate that an incontinent man with a
history of prostate enlargement might not be emptying his bladder adequately?
a. Do you leak urine when you cough or sneeze?
b. Do you need help getting to the toilet?
, c. Do you dribble urine constantly?
d. Does it burn when you pass your urine? - Answers :C (Incontinence characterized by
constant dribbling of urine is associated with incontinence associated with urinary
retention. . The other options point to stress incontinence, functional incontinence or a
UTI.)
The NAP reports to the nurse that a patient's catheter drainage bag has been empty for
4 hours. What is a priority nursing intervention?
a. Implement the "as needed" order to irrigate the catheter.
b. Assess the catheter and drainage tubing for obvious occlusion.
c. Notify the health care provider immediately.
d. Assess the vital signs and intake and output record. - Answers :B (The priority
nursing intervention is to ensure that there is not an occlusion in the catheter or
drainage tubing.)
What nursing intervention decreases the risk for catheter associated urinary tract
infection (CAUTI)?
a. Cleanse the urinary meatus 3-4 times daily with antiseptic solution.
b. Hang the urinary drainage bag below the level with the bladder.
c. Empty the urinary drainage bag daily.
d. Irrigate the urinary catheter with sterile water. - Answers :B (Evidenced based
interventions shown to decrease the risk for CAUTI include ensuring that there is a free
flow of urine from the catheter to the drainage bag.)
What should the nurse teach a young woman with a history of urinary tract infections
about UTI prevention? (Select all that apply.)
a. Keep the bowels regular.
b. Limit water intake to 1-2 glasses a day
c. Wear cotton underwear
d. Cleanse the perineum from front to back.
e. Practice pelvic muscle exercise (Kegel) daily. - Answers :A C D (All are interventions
that lead to healthy bladder habits. Adequate hydration will ensure that the bladder is
regularly flushed out and will help prevent a UTI. Pelvic muscle exercises promote
pelvic health but not necessarily prevent UTI.)
When a patient has fecal incontinence as a result of cognitive impairment, it may be
helpful to teach caregivers to do which of the following interventions?
a. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks
b. Use diapers and heavy padding on the bed
c. Initiate bowel or habit training program to promote continence
