A nurse assessing a client notes that the client has a constant
leakage of small amounts of urine and a bladder that is distended
and palpable. The nurse should associate these findings with
which of the following types of urinary incontinence?
a. Stress incontinence
b. Urge incontinence
c. Overflow incontinence
d. Reflex incontinence Correct Answers C
A nurse in a long-term care facility is caring for an older adult
client who has dementia and begins to have frequent episode of
urinary incontinence. After the provider determines no medical
cause for the client't incontinence, which of the following
interventions should the nurse initiate to manage this behavior?
a. Remind the client to tell the nurse when he has to urinate.
b. Use adult diapers to prevent frequent clothing changes.
c. Take the client to the bathroom every 2 hr.
d. Request a prescription for an indwelling urinary catheter.
Correct Answers C
A nurse in a long-term care facility is observing an assistant
personnel (AP) changing the linen for a client who has fecal
incontinence. Which of the following actions indicates that the
AP understands the principles of infection control?
a. Shakes the soiled linen to remove any toilet paper remnants
b. Places the soiled linen on the floor before bagging it
,c. Holds the soiled linen against her body while carrying it to the
linen bag
d. Places clean linen that touched the floor in the soiled linen
bag Correct Answers D
A nurse instructs a female client about collecting a midstream
urine sample. Which of the following client statements indicates
an understanding of the procedure?
a. "I'll urinate a little then stop."
b. "I'll use the cleansing wipe from front to back."
c. "I'll clean the inside of the container with a wipe."
d. "I'll use each cleansing wipe twice." Correct Answers B
A nurse is administering a tap water enema to a client who is
constipated. During the administration of the enema, the client
states he is having abdominal cramps. Which of the following
actions should the nurse take to relieve the client's discomfort?
a. Lower the height of the solution container.
b. Encourage the client to bear down.
c. Allow the client to expel some fluid before continuing.
d. Stop the enema and document that the client did not tolerate
the procedure. Correct Answers A
A nurse is assessing a client who has a colostomy. Which of the
following findings should the nurse report to the provider?
a. The stool is yellow-green.
b. The ostomy is draining frequently.
c. The stoma is pale in color.
, d. The skin around the stoma is red. Correct Answers C
a nurse is assessing a client who has fluid volume deficit. the
nurse should expect which of the following findings?
a. Decreased urine specific gravity
b. Decreased Hgb
c. Increased BUN
d. Increased urine ketones Correct Answers C
A nurse is assessing a client who has heart failure and is
prescribed furosemide. Which of the following findings is an
adverse effect of this medication?
a. weight gain
b. increased blood pressure
c. hypoglycemia
d. leg cramps Correct Answers D
a nurse is assessing a client who has hypokalemia as a result of
nausea, vomiting, and diarrhea. which of the following findings
should the nurse expect?
a. hyperactive reflexes
b. extreme thirst
c. weak, irregular pulse
d. paresthesia Correct Answers C
A nurse is assessing a client who has left-sided heart failure.
Which of the following findings should the nurse expect?