NUR 2474 Exam 2: Pharmacology for Professional Nursing
Exam 2
3) The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering
the enema, the nurse should place the client in which position?
a. Left Sims' position
b. Right Sims' position
c. On the left side of the body, with the head of the bed elevated 45 degrees
d. On the right side of the body, with the head of the bed elevated 45 degrees. - ANSWER:a
Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema
solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in
the Sims' position.
10) A nurse is assessing a patient who has had diarrhea for 4 days. Which of the following findings should
the nurse expect? (Select all that apply)
a. Bradycardia
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema - ANSWER:b, c, d
Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an elevated temperature, a
decrease in blood pressure, poor skin turgor, tachycardia, and weakened peripheral pulses. Peripheral
edema results from a fluid overload.
11) While a nurse is performing a cleansing enema, the client reports abdominal cramping. Which of the
following actions should the nurse take?
a. Have the client hold their breath briefly and bear down
b. Clamp the enema tubing
c. Remind the client that cramping is common at this time
d. Raise the level of the enema fluid container - ANSWER:b
Rationale: Clamp the enema tubing for 30 seconds to reduce intestinal spasms. Telling the client that
cramping is common is non therapeutic and implies that the client must tolerate the discomfort and that
the nurse cannot or will not do anything to ease it.
,12) A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic
procedure. Which of the following steps should the nurse take? (Select all that apply)
a. Warm the enema solution prior to instillation
b. Position the client on the left side with the right leg flexed forward
c. Lubricate the rectal tube or nozzle
d. Slowly insert the rectal tube about 5 cm (2 in)
e. Hang the enema container 61 cm (24 in) above the client's anus - ANSWER:a, b, c
Rationale: Warm enema solution because cold fluid can cause abdominal cramping, and hot fluid can
damage the intestinal mucosa. Place the client on the left side with the right leg flexed forward to
promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid
colon. Lubricate the tubing to prevent trauma or irritation to the rectal mucosa. The correct length of
insertion of an adult patient is 7.6 to 10.2 cm (3 to 4 in). The maximum recommended height to hang
enema container is 46 cm (18 in).
13) A nurse is teaching a client who reports stress urinary incontinence. Which of the following
instructions should the nurse include? (Select all that apply)
a. Limit total daily fluid intake
b. Decrease or avoid caffeine
c. Take calcium supplements
d. Avoid drinking alcohol
e. Use the Crede maneuver - ANSWER:b, d
Rationale: Alcohol and caffeine is a bladder irritant and can worsen stress incontinence. Stress
incontinence results from weak pelvic muscles and other structures, limiting fluids will not resolve the
problem.
14) A client with an indwelling catheter reports a need to urinate. Which of the following actions should
the nurse take?
a. Check to see whether the catheter is patent
b. Reassure the client that it is not possible for them to urinate
c. Recatheterize the bladder with a larger-gauge catheter
d. Collect a urine specimen for analysis - ANSWER:a
Rationale: A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.
15) A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the
following actions should the nurse take?
a. Discard the first voiding
, b. Keep the urine in a single container at room temperature
c. Dispose the last voiding
d. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen
container. - ANSWER:a
Rationale: Discard the first voiding of the 24-hour specimen and note the time. Voiding should be saved
until the end of the collection period.
16) A nurse is reviewing factors that increase the risk of a urinary tract infection (UTIs). Which of the
following factors should the nurse include? (Select all that apply)
a. Frequent sexual intercourse
b. Lowering of testosterone levels
c. Wiping from front to back to clean the perineum
d. Location of the urethra close to the anus
e. Frequent catheterization - ANSWER:a, d, e
Rationale: Having frequent sexual intercourse increases the risk of UTIs in all clients. The close proximity
of the urethra to the anus is a factor that increases the risk of an infection. Frequent catheterization and
the use of indwelling catheters are risk factors for UTIs.
17) A nurse is preparing to initiate a bladder training program for a client who has incontinence. Which
of the following actions should the nurse take? (Select all that apply)
a. Restrict the client's intake of fluids during the daytime
b. Have the client record urination times
c. Gradually increase the urination intervals
d. Remind the client to hold urine until next scheduled urination time
e. Provide a sterile container for urine - ANSWER:b, c, d
Rationale: Asking the client to keep track of urination times, gradually increasing the intervals between
urinations, and reminding the client to hold urine until the next scheduled time helps their progress
toward the goal of 4-hr intervals between urination.
18) A female patient complains of abdominal discomfort. Watery stool has been leaking from her
rectum. This could be a sign of
a. Diarrhea
b. Bowel incompetence
c. Fecal impaction - ANSWER:c
Exam 2
3) The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering
the enema, the nurse should place the client in which position?
a. Left Sims' position
b. Right Sims' position
c. On the left side of the body, with the head of the bed elevated 45 degrees
d. On the right side of the body, with the head of the bed elevated 45 degrees. - ANSWER:a
Rationale: For administering an enema, the client is placed in a left Sims' position so that the enema
solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated in
the Sims' position.
10) A nurse is assessing a patient who has had diarrhea for 4 days. Which of the following findings should
the nurse expect? (Select all that apply)
a. Bradycardia
b. Hypotension
c. Elevated temperature
d. Poor skin turgor
e. Peripheral edema - ANSWER:b, c, d
Rationale: Prolonged diarrhea leads to dehydration, expect the client to have an elevated temperature, a
decrease in blood pressure, poor skin turgor, tachycardia, and weakened peripheral pulses. Peripheral
edema results from a fluid overload.
11) While a nurse is performing a cleansing enema, the client reports abdominal cramping. Which of the
following actions should the nurse take?
a. Have the client hold their breath briefly and bear down
b. Clamp the enema tubing
c. Remind the client that cramping is common at this time
d. Raise the level of the enema fluid container - ANSWER:b
Rationale: Clamp the enema tubing for 30 seconds to reduce intestinal spasms. Telling the client that
cramping is common is non therapeutic and implies that the client must tolerate the discomfort and that
the nurse cannot or will not do anything to ease it.
,12) A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic
procedure. Which of the following steps should the nurse take? (Select all that apply)
a. Warm the enema solution prior to instillation
b. Position the client on the left side with the right leg flexed forward
c. Lubricate the rectal tube or nozzle
d. Slowly insert the rectal tube about 5 cm (2 in)
e. Hang the enema container 61 cm (24 in) above the client's anus - ANSWER:a, b, c
Rationale: Warm enema solution because cold fluid can cause abdominal cramping, and hot fluid can
damage the intestinal mucosa. Place the client on the left side with the right leg flexed forward to
promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid
colon. Lubricate the tubing to prevent trauma or irritation to the rectal mucosa. The correct length of
insertion of an adult patient is 7.6 to 10.2 cm (3 to 4 in). The maximum recommended height to hang
enema container is 46 cm (18 in).
13) A nurse is teaching a client who reports stress urinary incontinence. Which of the following
instructions should the nurse include? (Select all that apply)
a. Limit total daily fluid intake
b. Decrease or avoid caffeine
c. Take calcium supplements
d. Avoid drinking alcohol
e. Use the Crede maneuver - ANSWER:b, d
Rationale: Alcohol and caffeine is a bladder irritant and can worsen stress incontinence. Stress
incontinence results from weak pelvic muscles and other structures, limiting fluids will not resolve the
problem.
14) A client with an indwelling catheter reports a need to urinate. Which of the following actions should
the nurse take?
a. Check to see whether the catheter is patent
b. Reassure the client that it is not possible for them to urinate
c. Recatheterize the bladder with a larger-gauge catheter
d. Collect a urine specimen for analysis - ANSWER:a
Rationale: A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.
15) A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the
following actions should the nurse take?
a. Discard the first voiding
, b. Keep the urine in a single container at room temperature
c. Dispose the last voiding
d. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen
container. - ANSWER:a
Rationale: Discard the first voiding of the 24-hour specimen and note the time. Voiding should be saved
until the end of the collection period.
16) A nurse is reviewing factors that increase the risk of a urinary tract infection (UTIs). Which of the
following factors should the nurse include? (Select all that apply)
a. Frequent sexual intercourse
b. Lowering of testosterone levels
c. Wiping from front to back to clean the perineum
d. Location of the urethra close to the anus
e. Frequent catheterization - ANSWER:a, d, e
Rationale: Having frequent sexual intercourse increases the risk of UTIs in all clients. The close proximity
of the urethra to the anus is a factor that increases the risk of an infection. Frequent catheterization and
the use of indwelling catheters are risk factors for UTIs.
17) A nurse is preparing to initiate a bladder training program for a client who has incontinence. Which
of the following actions should the nurse take? (Select all that apply)
a. Restrict the client's intake of fluids during the daytime
b. Have the client record urination times
c. Gradually increase the urination intervals
d. Remind the client to hold urine until next scheduled urination time
e. Provide a sterile container for urine - ANSWER:b, c, d
Rationale: Asking the client to keep track of urination times, gradually increasing the intervals between
urinations, and reminding the client to hold urine until the next scheduled time helps their progress
toward the goal of 4-hr intervals between urination.
18) A female patient complains of abdominal discomfort. Watery stool has been leaking from her
rectum. This could be a sign of
a. Diarrhea
b. Bowel incompetence
c. Fecal impaction - ANSWER:c
