NUR 325 EXAM 2 REVIEW QUESTIONS
AND ALL VERIFIED ACCURATE
ANSWERS
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) - answer ✔✔-B
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 - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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.)
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. - answer ✔✔-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 - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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 - answer ✔✔-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 nursing assessment question would best indicate that an incontinent man with a history of
prostate enlargement might not be emptying his bladder adequately?
AND ALL VERIFIED ACCURATE
ANSWERS
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) - answer ✔✔-B
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 - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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.)
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. - answer ✔✔-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 - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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. - answer ✔✔-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 - answer ✔✔-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 nursing assessment question would best indicate that an incontinent man with a history of
prostate enlargement might not be emptying his bladder adequately?
