Nursing concepts exam 2 Troy U Final
Exam with Guaranteed Pass Solutions
2026 Updated.
A nurse caring for patients in a long-term care facility is often required to collect urine
specimens from patients for laboratory testing. Which techniques for urine collection are
performed correctly? Select all that apply. - Answer 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 a urinary diversion by catheterizing
the stoma.
f. The nurse discards the first urine of the day when performing a 24-hour urine specimen
collection on a patient.
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. - Answer a. A 78-year-old male patient diagnosed with an enlarged
prostate
c. A 75-year-old female patient who is diagnosed with vaginal prolapse
e. A 73-year-old female patient who is taking antihistamines to treat allergies
A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which
teaching points would the nurse include? Select all that apply. - Answer c. Drink eight to ten
8-oz glasses of water per day.
e. Limit caffeine-containing beverages.
f. Drink 10 oz of cranberry or blueberry juice daily.
4. A patient who has pneumonia has had a fever for 3 days. What characteristics would the
nurse anticipate related to the patient's urine output? - Answer Decreased and highly
concentrated (Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine
is concentrated and decreased in amount.)
The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What
consideration would the nurse keep in mind when performing this procedure? - Answer The
male urethra is more vulnerable to injury during insertion.
A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling
catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the
irrigant will not enter the catheter. What intervention would the nurse appropriately perform
next? - Answer Notify the primary care provider.
,A nurse is caring for a 56-year-old male patient diagnosed with bladder cancer who has a
urinary diversion. Which actions would the nurse take when caring for this patient? Select all
that apply - Answer a. Measure the patient's fluid intake and output.
c. Empty the appliance frequently.
f. Monitor the return of intestinal function and peristalsis.
A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the
stoma would alert the nurse that the patient is experiencing ischemia? - Answer The stoma
is a purple-blue color. (A purple-blue stoma may reflect compromised circulation or ischemia. A
pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should
subside with time. A normal stoma should be moist and dark pink to red in color.)
After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead
to an increased difficulty with voiding? - Answer Having the patient ignore the urge to void
until her bladder is full. (Ignoring the urge to void makes urination even more difficult and
should be avoided. The other activities are all recommended nursing activities to promote
voiding.)
A nurse caring for a patient's hemodialysis access documents the following: "5/10/15 0930
Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient
denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would
the nurse report to the primary care provider? - Answer Area is warm to touch and
edematous. (The nurse would report a site that is warm and edematous as this could be a sign
of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into
the vein. If these are not present, the access may be cutting off. No report of pain is a normal
finding.)
A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids
frequently and has difficulty making it to the bathroom in time. Which nursing intervention
would be most helpful for this patient? - Answer Teach the patient to perform Kegel
exercises at regular intervals daily.
A nurse is caring for a patient who is taking phenazopyridine (Pyridium, a urinary tract
analgesic). The patient questions the nurse: "My urine was bright orangish-red today; is there
something wrong with me?" What would be the nurse's best response? - Answer "This is a
normal finding when taking phenazopyridine." (Pyridium is noted for turning the urine orange-
red; the patient needs to be aware of this.)
A nurse is caring for a male patient who had a condom catheter applied following hip surgery.
What action would be a priority when caring for this patient? - Answer Preventing the tubing
from kinking to maintain free urinary drainage (The catheter should be allowed to drain freely
through tubing that is not kinked. It also should be removed daily to prevent skin excoriation
and should not be fastened too tightly or restriction of blood vessels in the area is likely.
Confining a patient to bedrest increases the risk for other hazards related to immobility.)
,A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination related
to maturational enuresis. Based on this diagnosis, for which patient is the nurse caring? -
Answer A child older than 4 years of age who has involuntary urination (Maturational
enuresis is involuntary urination after an age when continence should be present. A 12-month-
old child is not expected to be continent, and incontinence and neurologic damage are not
maturational problems.)
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in
an older adult patient. Which information is least important for the evaluation process? -
Answer Age of the patient (Incontinence is not a natural consequence of the aging process.
All the other factors are necessary information for the plan of care.)
The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the
hospital with a diagnosis of dehydration.
The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive
assessment and gather the appropriate patient data.
(2) First the nurse asks the patient about the most important details leading up to her diagnosis.
Then the nurse (3) collects as much information as possible to understand the patient's health
problems; (4) collects the patient data in an organized manner;
(5) verifies that the data obtained is pertinent to the patient care plan;
and (6) records the data according to facility's policy.
(1) ___________________________
(2) ___________________________
(3) ___________________________
(4) ___________________________
(5) ___________________________
(6) ___________________________ - Answer (1)Purposeful: The nurse identifies the
purpose of the nursing assessment (comprehensive) and gathers the appropriate data.
(2) Prioritized: The nurse gets the most important information first.
(3) Complete: The nurse gathers as much data as possible to understand the patient health
problem and develop a care plan.
(4) Systematic: The nurse gathers the information in an organized manner.
(5) Accurate and relevant: The nurse verifies that the information is reliable.
(6) Recorded in a standard format: The nurse records the data according to the facility's policy
so that all caregivers can easily access what is learned.
The nurse practitioner is performing a short assessment of a newborn who is displaying signs of
jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to
report to the primary care provider. What type of assessment has this nurse performed?
, 1. Comprehensive
2. Initial
3. Time-lapsed
4. Quick priority - Answer 4. Quick priority
(QPAs) are short, focused, prioritized assessments nurses do to gain the most important
information they need to have first. The comprehensive initial assessment is performed shortly
after the patient is admitted to a health care facility or service. The time-lapsed assessment is
scheduled to compare a patient's current status to baseline data obtained earlier.
The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of
preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when
the doctor just did one?" Which statements best explain the primary reasons a nursing
assessment is performed? Select all that apply.
1. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care
that draws on your strengths."
2. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!"
3. "I'm a student nurse and need to develop the skill of assessing your health status and need
for nursing care."
4. "We want to make sure that your responses to the medical exam are consistent and that all
our data are accurate."
5. "We need to check your health status and see what kind of nursing care you may need."
6. "We need to see if you require a referral to a physician or other health - Answer 1. "The
nursing assessment will allow us to plan and deliver individualized, holistic nursing care that
draws on your strengths."
5. "We need to check your health status and see what kind of nursing care you may need."
6. "We need to see if you require a referral to a physician or other health care professional."
Medical assessments target data pointing to pathologic conditions, whereas nursing
assessments focus on the patient's responses to health problems. The initial comprehensive
nursing assessment results in baseline data that enable the nurse to make a judgment about a
patient's health status, the ability to manage his or her own health care and the need for
nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on
the patient's strengths and promotes optimum functioning, independence, and well-being, and
enables the nurse to refer the patient to a physician or other health care professional, if
indicated. The fact that this is hospital policy is a secondary reason, and although it may be true
that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs
a nursing history and exam. The assessment is not performed to check the accuracy of the
medical examination.
Exam with Guaranteed Pass Solutions
2026 Updated.
A nurse caring for patients in a long-term care facility is often required to collect urine
specimens from patients for laboratory testing. Which techniques for urine collection are
performed correctly? Select all that apply. - Answer 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 a urinary diversion by catheterizing
the stoma.
f. The nurse discards the first urine of the day when performing a 24-hour urine specimen
collection on a patient.
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. - Answer a. A 78-year-old male patient diagnosed with an enlarged
prostate
c. A 75-year-old female patient who is diagnosed with vaginal prolapse
e. A 73-year-old female patient who is taking antihistamines to treat allergies
A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which
teaching points would the nurse include? Select all that apply. - Answer c. Drink eight to ten
8-oz glasses of water per day.
e. Limit caffeine-containing beverages.
f. Drink 10 oz of cranberry or blueberry juice daily.
4. A patient who has pneumonia has had a fever for 3 days. What characteristics would the
nurse anticipate related to the patient's urine output? - Answer Decreased and highly
concentrated (Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine
is concentrated and decreased in amount.)
The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What
consideration would the nurse keep in mind when performing this procedure? - Answer The
male urethra is more vulnerable to injury during insertion.
A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling
catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the
irrigant will not enter the catheter. What intervention would the nurse appropriately perform
next? - Answer Notify the primary care provider.
,A nurse is caring for a 56-year-old male patient diagnosed with bladder cancer who has a
urinary diversion. Which actions would the nurse take when caring for this patient? Select all
that apply - Answer a. Measure the patient's fluid intake and output.
c. Empty the appliance frequently.
f. Monitor the return of intestinal function and peristalsis.
A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the
stoma would alert the nurse that the patient is experiencing ischemia? - Answer The stoma
is a purple-blue color. (A purple-blue stoma may reflect compromised circulation or ischemia. A
pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should
subside with time. A normal stoma should be moist and dark pink to red in color.)
After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead
to an increased difficulty with voiding? - Answer Having the patient ignore the urge to void
until her bladder is full. (Ignoring the urge to void makes urination even more difficult and
should be avoided. The other activities are all recommended nursing activities to promote
voiding.)
A nurse caring for a patient's hemodialysis access documents the following: "5/10/15 0930
Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient
denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would
the nurse report to the primary care provider? - Answer Area is warm to touch and
edematous. (The nurse would report a site that is warm and edematous as this could be a sign
of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into
the vein. If these are not present, the access may be cutting off. No report of pain is a normal
finding.)
A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids
frequently and has difficulty making it to the bathroom in time. Which nursing intervention
would be most helpful for this patient? - Answer Teach the patient to perform Kegel
exercises at regular intervals daily.
A nurse is caring for a patient who is taking phenazopyridine (Pyridium, a urinary tract
analgesic). The patient questions the nurse: "My urine was bright orangish-red today; is there
something wrong with me?" What would be the nurse's best response? - Answer "This is a
normal finding when taking phenazopyridine." (Pyridium is noted for turning the urine orange-
red; the patient needs to be aware of this.)
A nurse is caring for a male patient who had a condom catheter applied following hip surgery.
What action would be a priority when caring for this patient? - Answer Preventing the tubing
from kinking to maintain free urinary drainage (The catheter should be allowed to drain freely
through tubing that is not kinked. It also should be removed daily to prevent skin excoriation
and should not be fastened too tightly or restriction of blood vessels in the area is likely.
Confining a patient to bedrest increases the risk for other hazards related to immobility.)
,A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination related
to maturational enuresis. Based on this diagnosis, for which patient is the nurse caring? -
Answer A child older than 4 years of age who has involuntary urination (Maturational
enuresis is involuntary urination after an age when continence should be present. A 12-month-
old child is not expected to be continent, and incontinence and neurologic damage are not
maturational problems.)
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in
an older adult patient. Which information is least important for the evaluation process? -
Answer Age of the patient (Incontinence is not a natural consequence of the aging process.
All the other factors are necessary information for the plan of care.)
The nurse is conducting an initial assessment of a 79-year-old female patient admitted to the
hospital with a diagnosis of dehydration.
The nurse (1) uses clinical reasoning to identify the need to perform a comprehensive
assessment and gather the appropriate patient data.
(2) First the nurse asks the patient about the most important details leading up to her diagnosis.
Then the nurse (3) collects as much information as possible to understand the patient's health
problems; (4) collects the patient data in an organized manner;
(5) verifies that the data obtained is pertinent to the patient care plan;
and (6) records the data according to facility's policy.
(1) ___________________________
(2) ___________________________
(3) ___________________________
(4) ___________________________
(5) ___________________________
(6) ___________________________ - Answer (1)Purposeful: The nurse identifies the
purpose of the nursing assessment (comprehensive) and gathers the appropriate data.
(2) Prioritized: The nurse gets the most important information first.
(3) Complete: The nurse gathers as much data as possible to understand the patient health
problem and develop a care plan.
(4) Systematic: The nurse gathers the information in an organized manner.
(5) Accurate and relevant: The nurse verifies that the information is reliable.
(6) Recorded in a standard format: The nurse records the data according to the facility's policy
so that all caregivers can easily access what is learned.
The nurse practitioner is performing a short assessment of a newborn who is displaying signs of
jaundice. The nurse observes the infant's skin color and orders a test for bilirubin levels to
report to the primary care provider. What type of assessment has this nurse performed?
, 1. Comprehensive
2. Initial
3. Time-lapsed
4. Quick priority - Answer 4. Quick priority
(QPAs) are short, focused, prioritized assessments nurses do to gain the most important
information they need to have first. The comprehensive initial assessment is performed shortly
after the patient is admitted to a health care facility or service. The time-lapsed assessment is
scheduled to compare a patient's current status to baseline data obtained earlier.
The nurse is admitting a 35-year-old pregnant woman to the hospital for treatment of
preeclampsia. The patient asks the nurse: "Why are you doing a history and physical exam when
the doctor just did one?" Which statements best explain the primary reasons a nursing
assessment is performed? Select all that apply.
1. "The nursing assessment will allow us to plan and deliver individualized, holistic nursing care
that draws on your strengths."
2. "It's hospital policy. I know it must be tiresome, but I will try to make this quick!"
3. "I'm a student nurse and need to develop the skill of assessing your health status and need
for nursing care."
4. "We want to make sure that your responses to the medical exam are consistent and that all
our data are accurate."
5. "We need to check your health status and see what kind of nursing care you may need."
6. "We need to see if you require a referral to a physician or other health - Answer 1. "The
nursing assessment will allow us to plan and deliver individualized, holistic nursing care that
draws on your strengths."
5. "We need to check your health status and see what kind of nursing care you may need."
6. "We need to see if you require a referral to a physician or other health care professional."
Medical assessments target data pointing to pathologic conditions, whereas nursing
assessments focus on the patient's responses to health problems. The initial comprehensive
nursing assessment results in baseline data that enable the nurse to make a judgment about a
patient's health status, the ability to manage his or her own health care and the need for
nursing. It also helps nurses plan and deliver individualized, holistic nursing care that draws on
the patient's strengths and promotes optimum functioning, independence, and well-being, and
enables the nurse to refer the patient to a physician or other health care professional, if
indicated. The fact that this is hospital policy is a secondary reason, and although it may be true
that a nurse may need to develop assessment skills, it is not the chief reason the nurse performs
a nursing history and exam. The assessment is not performed to check the accuracy of the
medical examination.
