NUR 325 EXAM 2 REVIEW QUESTIONS AND ANSWERS
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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. - CORRECT ANSWERS 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. - CORRECT ANSWERS 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
,NUR 325 EXAM 2 REVIEW QUESTIONS AND ANSWERS
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d. Dark amber urine - CORRECT ANSWERS 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. - CORRECT ANSWERS 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. - CORRECT ANSWERS 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.
,NUR 325 EXAM 2 REVIEW QUESTIONS AND ANSWERS
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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. - CORRECT ANSWERS 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 - CORRECT ANSWERS 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?
a. Do you leak urine when you cough or sneeze?
b. Do you need help getting to the toilet?
c. Do you dribble urine constantly?
d. Does it burn when you pass your urine? - CORRECT ANSWERS C (Incontinence
characterized by constant dribbling of urine is associated with incontinence associated with
urinary retention. . The other options point to stress incontinence, functional incontinence
or a UTI.)
The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4
hours. What is a priority nursing intervention?
, NUR 325 EXAM 2 REVIEW QUESTIONS AND ANSWERS
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a. Implement the "as needed" order to irrigate the catheter.
b. Assess the catheter and drainage tubing for obvious occlusion.
c. Notify the health care provider immediately.
d. Assess the vital signs and intake and output record. - CORRECT ANSWERS B (The priority
nursing intervention is to ensure that there is not an occlusion in the catheter or drainage
tubing.)
What nursing intervention decreases the risk for catheter associated urinary tract infection
(CAUTI)?
a. Cleanse the urinary meatus 3-4 times daily with antiseptic solution.
b. Hang the urinary drainage bag below the level with the bladder.
c. Empty the urinary drainage bag daily.
d. Irrigate the urinary catheter with sterile water. - CORRECT ANSWERS B (Evidenced based
interventions shown to decrease the risk for CAUTI include ensuring that there is a free flow
of urine from the catheter to the drainage bag.)
What should the nurse teach a young woman with a history of urinary tract infections about
UTI prevention? (Select all that apply.)
a. Keep the bowels regular.
b. Limit water intake to 1-2 glasses a day
c. Wear cotton underwear
d. Cleanse the perineum from front to back.
e. Practice pelvic muscle exercise (Kegel) daily. - CORRECT ANSWERS A C D (All are
interventions that lead to healthy bladder habits. Adequate hydration will ensure that the
bladder is regularly flushed out and will help prevent a UTI. Pelvic muscle exercises promote
pelvic health but not necessarily prevent UTI.)
When a patient has fecal incontinence as a result of cognitive impairment, it may be helpful
to teach caregivers to do which of the following interventions?
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