TEST BANK FOR DEWITS FUNDAMENTAL CONCEPTS AND SKILLS FOR NURSING 5TH EDITION BY WILLIAMS

1. The nurse caring for a severely dehydrated patient who has a Foley catheter in place assesses the patient to confirm adequate urine perfusion by the urine output of: a. 15 mL. b. 30 mL. c. 45 mL. d. 60 mL. ANS: B There should be an average hourly urine output of 30 mL. DIF: Cognitive Level: Knowledge REF: p. 543 OBJ: Clinical Practice #1 TOP: Urinary Output KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. To help reduce a patient’s risk of recurrent cystitis, the nurse teaches the patient to: a. eat citrus fruits to alkalinize the urine. b. always wipe the perineal area from back to front. c. take long, warm bubble baths. d. wear cotton underwear and avoid nylon or constrictive clothing. ANS: D The patient should wear cotton underwear and avoid nylon and constrictive clothing that worsens perineal moisture. DIF: Cognitive Level: Comprehension REF: p. 544 OBJ: Clinical Practice #1 TOP: Prevention of Urinary Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Detection of Disease 3. The nurse is aware that in the older adult, a urinary infection may cause the patient to: a. run an exceptionally high temperature. b. have foul urine and diarrhea. c. become disoriented and confused. d. become irritable. ANS: C Urinary infections in the older adult patient may not be manifested by fever. There are subtle changes in mental status. DIF: Cognitive Level: Comprehension REF: p. 544 OBJ: Clinical Practice #1 TOP: Urinary Infection in the Older Adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. To prevent changes in the chemical characteristics of urine, a nurse sends a sample of fresh urine to the laboratory for urinalysis within at least: a. 1 to 2 minutes. b. 3 to 5 minutes. c. 5 to 10 minutes. d. 20 to 30 minutes. ANS: C Urine that stands for 15 minutes or longer changes characteristics, and the urinalysis will no longer be accurate. DIF: Cognitive Level: Comprehension REF: p. 547 OBJ: Clinical Practice #1 TOP: Urinalysis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A patient has been ordered to have a 24-hour urine collection as part of a diagnostic workup. The action taken to perform this procedure correctly is to: a. continue the collection if the patient accidentally voids directly into the toilet. b. obtain a container and put it in a warm water bath in the bathroom. c. have the patient void at the beginning of the collection and throw it away. d. have the patient void for the last time a few hours before the collection ends. ANS: C The patient’s bladder should be empty when the test begins; for this reason, the urine obtained at the start time is discarded and the urine collected should be stored on ice during the 24-hour period. DIF: Cognitive Level: Application REF: p. 546 OBJ: Clinical Practice #1 TOP: 24 Hour Urine Collection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. A nurse would modify the urine collection technique when a urine sample is needed from an infant by: a. placing the infant on a bedpan after removing the diaper. b. removing the diaper after the infant voids and send the diaper to the laboratory. c. attaching a bag with adhesive backing to the skin surrounding the genitals. d. applying a very small condom catheter. ANS: C A urine collection bag is attached to the skin by an adhesive backing and is placed so that it surrounds the genitals; when sufficient urine is collected, the bag is removed and urine is put into a specimen cup to send to the laboratory. DIF: Cognitive Level: Application REF: p. 547 OBJ: Clinical Practice #1 TOP: Urinary Collection Bag KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing intervention in the care of such a patient would be to: a. place a sieve over the commode. b. obtain an order for indwelling urinary catheter. c. place a graduated cylinder near the commode. d. attach a urinary leg bag. ANS: A When a patient is suspected of having urolithiasis (a urinary stone), the urine is strained through a fine sieve. DIF: Cognitive Level: Application REF: p. 547 OBJ: Clinical Practice #1 TOP: Strained Urine Specimen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. When the patient who has an order to be out of bed complains of feeling too weak to walk to the bathroom, the nurse assists the patient with urination elimination by: a. acquiring a walker so that the patient can go to the bathroom. b. using a fracture bedpan and keep the patient flat. c. obtaining a raised toilet seat. d. placing a commode at the bedside. ANS: D A bedside commode allows the patient to get out of bed to void and does not tire the patient who feels weak. Allowing a weak patient to ambulate unassisted puts the patient at risk for a fall. DIF: Cognitive Level: Application REF: p. 548 OBJ: Clinical Practice #4 TOP: Urinary Elimination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 9. A nurse is observing a nursing assistant offering a bedpan to a patient. The nurse will intervene if the nursing assistant: a. closes the bedside curtain. b. dons clean gloves. c. keeps the head of the bed flat after placing the bedpan. d. asks the patient to bend his knees and press down with his feet. ANS: C The head of the bed should be raised to 30 degrees after the bedpan is placed unless specifically contraindicated. DIF: Cognitive Level: Application REF: p. 551|Skill 29-1 OBJ: Clinical Practice #4 TOP: Assisting with Toileting KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 10. The nurse can assist a patient who needs to void but cannot begin the urinary stream by: a. running water in a nearby sink. b. pouring cool water over the perineum. c. inserting an indwelling catheter. d. distracting the patient with conversation. ANS: A The sound of running water helps a patient to start voiding. DIF: Cognitive Level: Application REF: p. 553 OBJ: Theory #3 TOP: Strategies to Assist with Voiding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. An adult male patient who cannot void has an order to have a urinary catheter inserted. Which size catheter would be most appropriate to use? a. 12 French b. 16 French c. 18 French d. 22 French ANS: C The average sized urinary catheter used for an adult male is 18 to 20 French. DIF: Cognitive Level: Knowledge REF: p. 553 OBJ: Theory #4 TOP: Indwelling Catheter KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. An older adult male patient needs to have a condom catheter applied. An appropriate technique is to: a. shave the perineal area before beginning. b. apply povidone iodine to the penis before catheter application. c. apply an adhesive strip in a circle around the base of the penis. d. leave 1 to 2 inches between the tip of the penis and the drainage part of the catheter. ANS: D The catheter is placed so that 1 to 2 inches of space are left to allow for urine to drain away from the penis. DIF: Cognitive Level: Comprehension REF: p. 555|Skill 29-2 OBJ: Theory #6 TOP: Condom Catheter KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. A patient who underwent prostate surgery is admitted to the surgical unit with a catheter that is used to provide continuous irrigation. The nurse recognizes this catheter is a(n): a. Alcock. b. Malecot. c. Coudé catheter. d. de Pezzer catheter. ANS: A S - The Marketplace to Buy and Sell your Study Material Downloaded by: Jktechub | jktechub@ya