graded A+ already passed
1. A nurse notes Has a diminished capacity to form urine
documentation in a client's
medical record indicat- ing Rationale: Oliguria, diminished capacity to form
that the client is urine, is most often the result of a decrease in renal
experiencing oliguria. On perfusion.
the basis of this nota-
tion, the nurse determines that the Anuria is the inability to produce urine.
Polyuria is the
client voiding of excessively large amounts of urine.
: Urinary incontinence is the involuntary loss of
urine.
2. A nurse administers a tap water en- A Document the results
ema (1000 mL) to an adult client
who is constipated. The client defe- A Document the results
cates a scant amount of
brown fe- cal matter, which Rationale: Tap water is hypotonic, exerting a lower
the nurse inter- prets as a os- motic pressure than fluid in the interstitial
poor result. The nurse should: space. After infusion into the colon, tap water
escapes from the bow- el lumen into the interstitial
space. The net movement of water is low. The
infused volume stimulates defecation before large
amounts of water leave the bowel.
3. A nurse is inserting an
indwelling C Aspirating the fluid, advancing the catheter
farther,
urinary catheter into the urethra of and reinflating the balloon
a male client. As the nurse inflates
the balloon, the client is:
complains of discomfort. The
appropriate nurs- ing action
,NU270 Module 7 questions and correct answers
graded A+ already passed
Rationale: If the balloon is malpositioned in the
urethra, inflating the balloon could produce trauma,
resulting in pain. If pain occurs, the fluid should
be aspirated and the catheter inserted a little
farther to provide suflcient space in which to
4. inflate the balloon. The catheter's balloon is
behind the opening at the insertion tip. In-
serting the catheter the extra distance will ensure
that the balloon is inflated inside the bladder and
not in the urethra.
,NU270 Module 7 questions and correct answers
graded A+ already passed
A nurse has taught a client B 8 inches to the front and side of the toes
how to stand on crutches. The
nurse deter- mines that the Rationale: The classic tripod position is taught to
client understands the the client before giving instructions on gait. The
instructions if the client places crutches are placed between 6 and 10 inches in
the crutches: front and to the side of the client, depending on
the client's body size, providing a wide enough
base of support and improving the client's
balance
5. A nurse has provided dietary C Scallops ,Chicken liver
in- structions to a client with
a new di- agnosis of gout. Rationale: Organ meats such as liver, as well as
Which menu sug- gestions by certain sea foods, including scallops, sardines,
the client indicate to the and herring, should be omitted from the diet of the
nurse that the client needs client who with gout because of the high purine
ad- ditional instruction? content.
Select all that apply.
6. A client who has sustained multiple C Right heel
fractures of the left leg is in skeletal
traction. The nurse has obtained an Rationale: Certain areas are under pressure
and at risk
overhead trapeze to breakdown?
improve the client's bed
mobility. To which of the
7. A nurse has a prescription to
following high-risk areas
get
must the nurse pay
particular attention during
assessment for indications of
pressure and skin
, NU270 Module 7 questions and correct answers
graded A+ already passed
for breakdown in the client who is in skeletal Other such pressure points include the ischial
traction. These areas include the elbows (if they tuberosity, popliteal space, and Achilles ten- don.
are used for repositioning instead of a trapeze)
and the heel of the good leg, which is used as a D Applying a knee immobilizer before getting the
client
brace when the client push- es up from the bed).
the client out of bed and into a chair up, then elevating the attected leg while the
client is
on the first postoperative sitting
day af- ter total knee
replacement. Which Rationale: The nurse helps the client get out of
bed after