Fundamentals; Exam 3 Practice Questions with 100%
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A patient who is moved to a hospital bed following throat surgery is ordered to
receive continuous tube feedings through a small-bore nasogastic tube. Following
placement of the tube, which nursing action would the nurse initiate to ensure
correct placement of the tube?
A. Auscultate the bowel sounds
B. Measure the gastric aspirate ph
C. Measure the amount of residual in the tube
D. order radiographic examination of the tube - ANSWER -D
Which of the following nursing diagnoses would be most appropriate for a patient
with a body mass index of 18?
A. Risk for Imbalanced Nutrition: More Than Body Requirements
B. Imbalanced Nutrition: More than Body Requirements
C. Readiness for Enhanced Nutrition
D. Imbalanced Nutrition: Less than Body Requirements - ANSWER -D
exp.) BMI of 18 is considered underweight
A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in
his GI tract. When the tube is being passed through the pharynx, the patient begins
to cough and shows signs of respiratory distress. What would be the priority action
of the nurse upon this assessment?
A. Keep the tube in place and notify the primary HCP immediately
B. Stop advancing the tube and pull it back into the nasal area
C. Ask the patient if he wants the nurse to stop the procedure
D. Call for help for perform CPR - ANSWER -B
A nurse is administering a tube feeding for a patient who is post bowel surgery.
When attempting to aspirate the contents, the nurse notes that the tube is clogged.
What would be the nurses next action following this assessment?
A. Use warm water and gentle pressure to remove the clog
B. Use a stylet to unclog the tube
C. Administer cola to unclog the tube
D. Replace the tube with a new one - ANSWER -A
, A nurse performs surgical assessments of patients in an ambulatory care center.
Which patient would the nurse report to the surgeon as possibly needing surgery to
be postponed?
A. A 19 year old patient who is vegan
B. An elderly patient who takes daily nutritional drinks
C. A 43 year old patient who takes gingko bilboa and an aspirin daily
D. An infant who is breast feeding - ANSWER -C
exp.) A patient taking gingko biloba (an herbal) aspirin and vitamin E may have to
have surgery postponed due to an increase risk for excessive bleeding, because
each of those substances have anticoagulant properties.
A nurse is a providers office is evaluating a client who reports losing control of
urine whenever she coughs, laughs, or sneezes. The client relates a history of three
vaginal births, but no serious accidents or illnesses. Which of the following
interventions should the nurse suggest for helping to control or eliminate the
client's incontinence? (Select all that apply).
A. Limit total daily fluid intake
B. Decrease or avoid caffeine
C. Take calcium supplements
D. Avoid drinking alcohol
E. Use the crede maneuver - ANSWER -B, D
A client who has an indwelling catheter reports a need to urinate. Which of the
following actions should the nurse take?
A. Check to see whether the catheter is patent
B. Reassure the client that it is not possible for her to urinate
C. Recatheterize the bladder with a larger-gauge catheter
D. Collect a urine specimen for analysis - ANSWER -A
exp.) a clogging or kinked catheter causes the bladder to fill and stimulates the
need to urinate
A nurse is caring for a client who has a prescription for a 24 hr urine collection.
Which of the following actions should the nurse take?
A. Discard the first voiding
B. Keep the urine in a single container at room temperature
C. Ask the client to urinate and pour the urine into a specimen container
D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into
the specimen container - ANSWER -A
exp.) the nurse should discard the first voiding of the 24 hr urine specimen and
note the time
, A nurse is reviewing factors that increase the risk of urinary tract infections with a
client who has recurrent UTI's. Which of the following factors should the nurse
include? (Select all that apply)
A. Frequent sexual intercourse
B. Lowering of testosterone levels
C. Wiping from front to back
D. Location of the urethra in relation to the anus
E. Frequent catheterization - ANSWER -A, D, E
A nurse is preparing to initiate a bladder-retraining program for a client who has
incontinence. Which of the following actions should the nurse take? (Select all that
apply)
A. Establish a schedule of urinating prior to meal times
B. Have the client record urination times
C. Gradually increase urination intervals
D. Remind the client to hold urine until the next scheduled urination time
E. Provide a sterile container for urine - ANSWER -B, C, D
A nurse caring for patients in a long-term care facility is often required to collect
urine specimens from patients for lab testing. Which techniques for urine
collection are performed correctly? (Select all that apply)
A. The nurse catheterizes a patient to collect a sterile urine sample for routine
urinalysis.
B. The nurse collects a clean-catch urine specimen in the morning from a patient
and stores it at room temperature until an afternoon pick up.
C. The nurse collects a sterile urine specimen from the collection receptacle of a
patient's indwelling catheter.
D. The nurse collects about 3 mL of urine from a patient's indwelling catheter to
send for a urine culture
E. The nurse collects a urine specimen from a patient with urinary diversion by
catheterizing the stoma.
F. The nurse discards the first urine of the day when performing a 24 hr urine
specimen collection on a patient. - ANSWER -D, E, F
A nurse caring for patients in an extended-care facility performs regular
assessments of the patients' urinary functioning. Which patients would the nurse
screen for urinary retention. (Select all that apply).
A. A 78 year old patient diagnosed with an enlarged prostate.
B. An 83 year old female patient who is on bed rest.
Verified Solutions |latest updates|
A patient who is moved to a hospital bed following throat surgery is ordered to
receive continuous tube feedings through a small-bore nasogastic tube. Following
placement of the tube, which nursing action would the nurse initiate to ensure
correct placement of the tube?
A. Auscultate the bowel sounds
B. Measure the gastric aspirate ph
C. Measure the amount of residual in the tube
D. order radiographic examination of the tube - ANSWER -D
Which of the following nursing diagnoses would be most appropriate for a patient
with a body mass index of 18?
A. Risk for Imbalanced Nutrition: More Than Body Requirements
B. Imbalanced Nutrition: More than Body Requirements
C. Readiness for Enhanced Nutrition
D. Imbalanced Nutrition: Less than Body Requirements - ANSWER -D
exp.) BMI of 18 is considered underweight
A nurse is inserting a nasogastric tube ordered for a patient to monitor bleeding in
his GI tract. When the tube is being passed through the pharynx, the patient begins
to cough and shows signs of respiratory distress. What would be the priority action
of the nurse upon this assessment?
A. Keep the tube in place and notify the primary HCP immediately
B. Stop advancing the tube and pull it back into the nasal area
C. Ask the patient if he wants the nurse to stop the procedure
D. Call for help for perform CPR - ANSWER -B
A nurse is administering a tube feeding for a patient who is post bowel surgery.
When attempting to aspirate the contents, the nurse notes that the tube is clogged.
What would be the nurses next action following this assessment?
A. Use warm water and gentle pressure to remove the clog
B. Use a stylet to unclog the tube
C. Administer cola to unclog the tube
D. Replace the tube with a new one - ANSWER -A
, A nurse performs surgical assessments of patients in an ambulatory care center.
Which patient would the nurse report to the surgeon as possibly needing surgery to
be postponed?
A. A 19 year old patient who is vegan
B. An elderly patient who takes daily nutritional drinks
C. A 43 year old patient who takes gingko bilboa and an aspirin daily
D. An infant who is breast feeding - ANSWER -C
exp.) A patient taking gingko biloba (an herbal) aspirin and vitamin E may have to
have surgery postponed due to an increase risk for excessive bleeding, because
each of those substances have anticoagulant properties.
A nurse is a providers office is evaluating a client who reports losing control of
urine whenever she coughs, laughs, or sneezes. The client relates a history of three
vaginal births, but no serious accidents or illnesses. Which of the following
interventions should the nurse suggest for helping to control or eliminate the
client's incontinence? (Select all that apply).
A. Limit total daily fluid intake
B. Decrease or avoid caffeine
C. Take calcium supplements
D. Avoid drinking alcohol
E. Use the crede maneuver - ANSWER -B, D
A client who has an indwelling catheter reports a need to urinate. Which of the
following actions should the nurse take?
A. Check to see whether the catheter is patent
B. Reassure the client that it is not possible for her to urinate
C. Recatheterize the bladder with a larger-gauge catheter
D. Collect a urine specimen for analysis - ANSWER -A
exp.) a clogging or kinked catheter causes the bladder to fill and stimulates the
need to urinate
A nurse is caring for a client who has a prescription for a 24 hr urine collection.
Which of the following actions should the nurse take?
A. Discard the first voiding
B. Keep the urine in a single container at room temperature
C. Ask the client to urinate and pour the urine into a specimen container
D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into
the specimen container - ANSWER -A
exp.) the nurse should discard the first voiding of the 24 hr urine specimen and
note the time
, A nurse is reviewing factors that increase the risk of urinary tract infections with a
client who has recurrent UTI's. Which of the following factors should the nurse
include? (Select all that apply)
A. Frequent sexual intercourse
B. Lowering of testosterone levels
C. Wiping from front to back
D. Location of the urethra in relation to the anus
E. Frequent catheterization - ANSWER -A, D, E
A nurse is preparing to initiate a bladder-retraining program for a client who has
incontinence. Which of the following actions should the nurse take? (Select all that
apply)
A. Establish a schedule of urinating prior to meal times
B. Have the client record urination times
C. Gradually increase urination intervals
D. Remind the client to hold urine until the next scheduled urination time
E. Provide a sterile container for urine - ANSWER -B, C, D
A nurse caring for patients in a long-term care facility is often required to collect
urine specimens from patients for lab testing. Which techniques for urine
collection are performed correctly? (Select all that apply)
A. The nurse catheterizes a patient to collect a sterile urine sample for routine
urinalysis.
B. The nurse collects a clean-catch urine specimen in the morning from a patient
and stores it at room temperature until an afternoon pick up.
C. The nurse collects a sterile urine specimen from the collection receptacle of a
patient's indwelling catheter.
D. The nurse collects about 3 mL of urine from a patient's indwelling catheter to
send for a urine culture
E. The nurse collects a urine specimen from a patient with urinary diversion by
catheterizing the stoma.
F. The nurse discards the first urine of the day when performing a 24 hr urine
specimen collection on a patient. - ANSWER -D, E, F
A nurse caring for patients in an extended-care facility performs regular
assessments of the patients' urinary functioning. Which patients would the nurse
screen for urinary retention. (Select all that apply).
A. A 78 year old patient diagnosed with an enlarged prostate.
B. An 83 year old female patient who is on bed rest.
