NUR 215 Exam 5 with accurate |! |! |! |! |! |!
detailed solutions |!
What signs and symptoms will your patient have if they have fluid volume
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excess? - Correct answer ✔-crackles |! |! |! |!
-high blood pressure|! |!
-swollen legs |!
-bounding pulse |!
-difficulty breathing |!
The nurse knows that the results of a fecal occult blood test can be inaccurate
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if:
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A.The client has had an excessive intake of red meat
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B.The client is menstruating
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C.The client takes high doses of vitamin C
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D.All of the above - Correct answer ✔D.All of the above
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Mrs. Addie is 70 years old. While the nurse is gathering admission
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assessment data, the patient states, "I've taken a tablespoon of Milk of
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Magnesia every day for 3 years." Which nursing diagnosis is most appropriate
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for the nurse to use in their plan of care?
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A.Diarrhea
B.Constipation
C.Risk for Ineffective Therapeutic Regimen
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,D.Perceived Constipation - Correct answer ✔D.Perceived Constipation
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You are caring for a patient with a colostomy. In order to provide safe care,
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you understand that when irrigating a colostomy a proper fitting cone is
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needed to prevent: |! |!
A.Introducing air into the colon |! |! |! |!
B.Leaking the solution around the stoma |! |! |! |! |!
C.Administering the solution too rapidly |! |! |! |!
D.Introduction of bacteria from the stoma - Correct answer ✔B.Leaking the |! |! |! |! |! |! |! |! |! |! |!
solution around the stoma |! |! |!
The nurse is administering a blood transfusion to a patient in shock. After 30
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min the patient spikes a fever and reports chest pain. Their blood pressure
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falls suddenly and they become tachycardic. What type of reaction is this
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patient experiencing? - Correct answer ✔hemolytic
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The nurse is assisting the client in caring for their ostomy. The client states,
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"Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's
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best response is:
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A."I'm sure you will get used to taking care of it eventually."
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B."Yes, it is pretty messy, so I'll take care of it for you today."
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C."It sounds like you are really upset."
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D."You sound very angry. Should I call the chaplain for you?" - Correct
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answer ✔B."Yes, it is pretty messy, so I'll take care of it for you
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, The female client states to the nurse, "I'm so distressed. It seems like every
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time I laugh hard, I wet myself." The nurse knows that this condition is
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known as: |!
A.Stress incontinence |!
B.Urge incontinence |!
C.Functional incontinence |!
D.Unconscious incontinence - Correct answer ✔A.Stress incontinence |! |! |! |! |! |!
The nurse prepares to insert an indwelling urinary catheter. Which statement
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least explains the reason for this intervention?
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A.Empty your bladder prior to your procedure.
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B.Treat your problem of leaking urine.
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C.Obtain a sterile urine specimen for culture.
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D.Measure the amount of urine left after you emptied your bladder. - Correct
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answer ✔B.Treat your problem of leaking urine.
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There is a 24-hr urine collection in process for a client. The unlicensed
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assistive personnel (UAP) inadvertently empties one specimen into the toilet
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instead of the collection "hat." The nurse should:
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A.Continue with the collection of urine until the 24-hr time period is
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finished.
B.Make a note to the lab to inform them that one specimen was missed
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during the collection. |! |!
C.Begin filling a new collection container and take both containers to the lab
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at the end of the collection period.
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detailed solutions |!
What signs and symptoms will your patient have if they have fluid volume
|! |! |! |! |! |! |! |! |! |! |! |! |!
excess? - Correct answer ✔-crackles |! |! |! |!
-high blood pressure|! |!
-swollen legs |!
-bounding pulse |!
-difficulty breathing |!
The nurse knows that the results of a fecal occult blood test can be inaccurate
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
if:
|!
A.The client has had an excessive intake of red meat
|! |! |! |! |! |! |! |! |!
B.The client is menstruating
|! |! |!
C.The client takes high doses of vitamin C
|! |! |! |! |! |! |!
D.All of the above - Correct answer ✔D.All of the above
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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 their plan of care?
|! |! |! |! |! |! |! |! |!
A.Diarrhea
B.Constipation
C.Risk for Ineffective Therapeutic Regimen
|! |! |! |!
,D.Perceived Constipation - Correct answer ✔D.Perceived 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: |! |!
A.Introducing air into the colon |! |! |! |!
B.Leaking the solution around the stoma |! |! |! |! |!
C.Administering the solution too rapidly |! |! |! |!
D.Introduction of bacteria from the stoma - Correct answer ✔B.Leaking the |! |! |! |! |! |! |! |! |! |! |!
solution around the stoma |! |! |!
The nurse is administering a blood transfusion to a patient in shock. After 30
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
min the patient spikes a fever and reports chest pain. Their blood pressure
|! |! |! |! |! |! |! |! |! |! |! |! |!
falls suddenly and they become tachycardic. What type of reaction is this
|! |! |! |! |! |! |! |! |! |! |! |!
patient experiencing? - Correct answer ✔hemolytic
|! |! |! |! |!
The nurse is assisting the client in caring for their ostomy. The client states,
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
"Oh, this is so disgusting. I'll never be able to touch this thing." The nurse's
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
best response is:
|! |!
A."I'm sure you will get used to taking care of it eventually."
|! |! |! |! |! |! |! |! |! |! |!
B."Yes, it is pretty messy, so I'll take care of it for you today."
|! |! |! |! |! |! |! |! |! |! |! |! |!
C."It sounds like you are really upset."
|! |! |! |! |! |!
D."You sound very angry. Should I call the chaplain for you?" - Correct
|! |! |! |! |! |! |! |! |! |! |! |! |!
answer ✔B."Yes, it is pretty messy, so I'll take care of it for you
|! |! |! |! |! |! |! |! |! |! |! |! |!
, 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 - Correct answer ✔A.Stress incontinence |! |! |! |! |! |!
The nurse prepares to insert an indwelling urinary catheter. Which statement
|! |! |! |! |! |! |! |! |! |! |!
least explains the reason for this intervention?
|! |! |! |! |! |!
A.Empty your bladder prior to your procedure.
|! |! |! |! |! |!
B.Treat your problem of leaking urine.
|! |! |! |! |!
C.Obtain a sterile urine specimen for culture.
|! |! |! |! |! |!
D.Measure the amount of urine left after you emptied your bladder. - Correct
|! |! |! |! |! |! |! |! |! |! |! |! |!
answer ✔B.Treat your problem of leaking urine.
|! |! |! |! |! |!
There is a 24-hr urine collection in process for a client. The unlicensed
|! |! |! |! |! |! |! |! |! |! |! |! |!
assistive personnel (UAP) 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.
|! |! |! |! |! |!
