NU 270 Module 7 Practice Questions and Correct Answers
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Course
NUR 270
Institution
NUR 270
A nurse notes documentation in a client's medical record indicating that the client is experiencing oliguria. On the basis of this notation, the nurse determines that the client: Has a diminished capacity to form urine
Rationale: Oliguria, diminished capacity to form urine, is most often the resul...
NU 270 Module 7 Practice Questions and
Correct Answers
A nurse notes documentation in a client's medical record indicating that the client is
experiencing oliguria. On the basis of this notation, the nurse determines that the client:
✅Has a diminished capacity to form urine
Rationale: Oliguria, diminished capacity to form urine, is most often the result of a
decrease in renal perfusion. Anuria is the inability to produce urine. Polyuria is the
voiding of excessively large amounts of urine. Urinary incontinence is the involuntary
loss of urine.
A nurse administers a tap water enema (1000 mL) to an adult client who is constipated.
The client defecates a scant amount of brown fecal matter, which the nurse interprets
as a poor result. The nurse should: ✅A Document the results
A Document the results
Rationale: Tap water is hypotonic, exerting a lower osmotic pressure than fluid in the
interstitial space. After infusion into the colon, tap water escapes from the bowel lumen
into the interstitial space. The net movement of water is low. The infused volume
stimulates defecation before large amounts of water leave the bowel.
A nurse is inserting an indwelling urinary catheter into the urethra of a male client. As
the nurse inflates the balloon, the client complains of discomfort. The appropriate
nursing action is: ✅C Aspirating the fluid, advancing the catheter farther, and
reinflating the balloon
Rationale: If the balloon is malpositioned in the urethra, inflating the balloon could
produce trauma, resulting in pain. If pain occurs, the fluid should be aspirated and the
catheter inserted a little farther to provide sufficient space in which to inflate the balloon.
The catheter's balloon is behind the opening at the insertion tip. Inserting the catheter
the extra distance will ensure that the balloon is inflated inside the bladder and not in
the urethra.
A nurse has taught a client how to stand on crutches. The nurse determines that the
client understands the instructions if the client places the crutches: ✅B 8 inches to the
front and side of the toes
Rationale: The classic tripod position is taught to the client before giving instructions on
gait. The crutches are placed between 6 and 10 inches in front and to the side of the
client, depending on the client's body size, providing a wide enough base of support and
improving the client's balance
, A nurse has provided dietary instructions to a client with a new diagnosis of gout. Which
menu suggestions by the client indicate to the nurse that the client needs additional
instruction? Select all that apply. ✅C Scallops ,Chicken liver
Rationale: Organ meats such as liver, as well as certain sea foods, including scallops,
sardines, and herring, should be omitted from the diet of the client who with gout
because of the high purine content.
A client who has sustained multiple fractures of the left leg is in skeletal traction. The
nurse has obtained an overhead trapeze to improve the client's bed mobility. To which
of the following high-risk areas must the nurse pay particular attention during
assessment for indications of pressure and skin breakdown? ✅C Right heel
Rationale: Certain areas are under pressure and at risk for breakdown in the client who
is in skeletal traction. These areas include the elbows (if they are used for repositioning
instead of a trapeze) and the heel of the good leg, which is used as a brace when the
client pushes up from the bed). Other such pressure points include the ischial
tuberosity, popliteal space, and Achilles tendon.
A nurse has a prescription to get the client out of bed and into a chair on the first
postoperative day after total knee replacement. Which of the following actions should
the nurse take to protect the knee? ✅D Applying a knee immobilizer before getting the
client up, then elevating the affected leg while the client is sitting
Rationale: The nurse helps the client get out of bed after putting a knee immobilizer on
the affected joint for stability. A compression dressing (a.k.a. elastic wrap or Ace
bandage) is usually applied after the surgical procedure is complete. The surgeon
prescribes weight-bearing limits on the affected leg. The leg is elevated while the client
is sitting in a chair to minimize edema. The CPM machine is used while the client is in
bed.
Which client does the nurse recognize as being at the greatest risk for injury resulting
from the use of heat or cold application? ✅A An older client
Rationale: Older clients have diminished sensitivity to pain and are therefore at great
risk for injury from heat or cold applications. Other clients at risk for injury are the very
young; those with open wounds; those with spinal cord injuries or peripheral vascular
disorders, such as the client with diabetes mellitus; and those who are confused or
unconscious.
A nurse provides information to a client about the importance of consuming fluids every
day. If the client has no renal or cardiac disease or any other disorder requiring fluid
alterations, how many milliliters of fluid should the nurse recommend that the client
consume each day? ✅D 2000 to 2500 mL
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