NUR215 EXAM 4 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
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 - (ANSWER)A.Stress incontinence
Stress incontinence results from increased pressure within the abdominal cavity.
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. - (ANSWER)B.Treat your problem of
leaking urine.
Insertion of a urinary catheter is not a "treatment" for incontinence.
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.
D.Dispose of the urine already collected and begin an entirely new 24-hr collection. -
(ANSWER)D.Dispose of the urine already collected and begin an entirely new 24-hr collection.
Once one specimen is missed during a 24-hr urine collection, the results of the laboratory test will be
inaccurate, and the collection must be restarted.
,NUR215 EXAM 4 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
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 - (ANSWER)D.Perceived Constipation
Daily laxative use by the patient might suggest that she perceives she is constipated, and the nurse
would gather further assessment data related to the client's bowel pattern. There is not enough data to
infer actual 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 - (ANSWER)B.Leaking the solution around the stoma
A proper fitting cone prevents leakage of the solution around the stoma that may cause irritation and
damage to the skin surrounding the stoma.
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?" - (ANSWER)C."It sounds like you are really
upset."
This statement reflects the principles of therapeutic communication.
, NUR215 EXAM 4 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
A patient who is obese is admitted with a diagnosis of congestive heart failure. The nursing history
reveals the patient has diabetes, smokes 2 packs of cigarettes daily, and is noncompliant with diet,
exercise, and medications. The student nurse assigned to the patient states, "Let's focus on making
them compliant, which will solve all the problems. Otherwise, we can't help them." What is the most
appropriate response?
A."Let's explore reasons for the noncompliance."
B."This statement shows a bias against the patient."
C."Let's discuss how you derived your priority of care."
D."What do you know about congestive heart failure?" - (ANSWER)
On assessment of a patient with acute renal failure, the nurse finds the following: distended neck veins,
cool and pale skin, and crackles in the lungs. The nurse should suspect the patient is experiencing:
A.Hypocalcemia
B.Hypovolemia
C.Hypervolemia
D.Hypercalcemia - (ANSWER)C.Hypervolemia
This patient is showing signs of fluid overload, or hypervolemia. Other findings include elevated blood
pressure, bounding pulse, and increased respirations due to increased intravascular volume.
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?
A.Allergic
B.Febrile
C.Hemolytic
D.Circulatory overload - (ANSWER)C.Hemolytic
This patient is showing signs of a hemolytic reaction, which is destruction of red blood cells. This occurs
when infusing incompatible blood (high antibody response). This complication is rare, but fatal.
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 - (ANSWER)A.Stress incontinence
Stress incontinence results from increased pressure within the abdominal cavity.
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. - (ANSWER)B.Treat your problem of
leaking urine.
Insertion of a urinary catheter is not a "treatment" for incontinence.
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.
D.Dispose of the urine already collected and begin an entirely new 24-hr collection. -
(ANSWER)D.Dispose of the urine already collected and begin an entirely new 24-hr collection.
Once one specimen is missed during a 24-hr urine collection, the results of the laboratory test will be
inaccurate, and the collection must be restarted.
,NUR215 EXAM 4 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
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 - (ANSWER)D.Perceived Constipation
Daily laxative use by the patient might suggest that she perceives she is constipated, and the nurse
would gather further assessment data related to the client's bowel pattern. There is not enough data to
infer actual 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 - (ANSWER)B.Leaking the solution around the stoma
A proper fitting cone prevents leakage of the solution around the stoma that may cause irritation and
damage to the skin surrounding the stoma.
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?" - (ANSWER)C."It sounds like you are really
upset."
This statement reflects the principles of therapeutic communication.
, NUR215 EXAM 4 QUESTIONS AND VERIFIED SOLUTIONS 2024/2025
A patient who is obese is admitted with a diagnosis of congestive heart failure. The nursing history
reveals the patient has diabetes, smokes 2 packs of cigarettes daily, and is noncompliant with diet,
exercise, and medications. The student nurse assigned to the patient states, "Let's focus on making
them compliant, which will solve all the problems. Otherwise, we can't help them." What is the most
appropriate response?
A."Let's explore reasons for the noncompliance."
B."This statement shows a bias against the patient."
C."Let's discuss how you derived your priority of care."
D."What do you know about congestive heart failure?" - (ANSWER)
On assessment of a patient with acute renal failure, the nurse finds the following: distended neck veins,
cool and pale skin, and crackles in the lungs. The nurse should suspect the patient is experiencing:
A.Hypocalcemia
B.Hypovolemia
C.Hypervolemia
D.Hypercalcemia - (ANSWER)C.Hypervolemia
This patient is showing signs of fluid overload, or hypervolemia. Other findings include elevated blood
pressure, bounding pulse, and increased respirations due to increased intravascular volume.
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?
A.Allergic
B.Febrile
C.Hemolytic
D.Circulatory overload - (ANSWER)C.Hemolytic
This patient is showing signs of a hemolytic reaction, which is destruction of red blood cells. This occurs
when infusing incompatible blood (high antibody response). This complication is rare, but fatal.
