The nurse recognizes that urinary illumination changes make her even in
healthy older adults because of which of the following? ✔️Ans - The
amount of urine retain after voiding increases
During assessment of the client with urinary incontinence, the nurse is
most likely to assess which of the following? ✔️Ans - perennial skin
irritation
fluid intake of less than 1500 mL/day
history of frequent urinary track infections
A fecal impaction
Which action represents the appropriate nursing management of a client
wearing a condom catheter? ✔️Ans - Check the penis for adequate
circulation 30 minutes after applying
The catheter slips into the vagina during a straight catheterization of a
female client. The nurse does which action? ✔️Ans - Leaves a catheter
in place and gets a new sterile catheter.
Which statement indicates a need for farther teaching of the home care
client with a long-term indwelling catheter? ✔️Ans - Soaking in a warm
tub bath may ease the irritation associated with the catheter
During shift report the nurse learns that an older female client is unable to
maintain continents after she is senses the urge to void and becomes
incontinence on the way to the bathroom. Which nursing diagnosis is most
appropriate? ✔️Ans - Urge urinary incontinence
A female client has a urinary track infection. Which teaching points by the
nurse will be most helpful for the client? Select all that apply. ✔️Ans -
Review symptoms of UTI with client
where cotton underclothes
The nurse will need to assess the clients performance of clean intermittent
sterile catheterization for a client with which urinary diversion? ✔️Ans -
Koch pouch
, Which focus is the nurse most likely to teach for a client with a flaccid
bladder? ✔️Ans - Credes maneuver: apply gentle manual pressure to the
lower abdomen
Which of the following behaviors indicate that the client on a bladder
training program has met expected outcomes? Select all that apply ✔️
Ans - Practice is slow, deep breathing until the urge decreases
performs pelvic muscle exercise
Which of the following behaviors is most representative of the nursing
diagnosis phase of the nursing process? ✔️Ans - Identify major
problems or needs
Which of the following behaviors would indicate that the nurse was
utilizing the assessment phase of the nursing process to provide nursing
care? ✔️Ans - Reviews results of laboratory test
Which of the following elements is best categorized as secondary
subjective data? ✔️Ans - Spouse states the client has lost all appetite
The nurse wishes to determine the clients feelings about a recent
diagnosis. Which interview question is most likely to elicit this
information? ✔️Ans - Tell me about your reaction to the diagnosis
The use of a conceptual or theoretical framework for collecting and
organizing assessment data ensures which of the following ✔️Ans -
Collection of all necessary information for a thorough appraisal
Which of the following is a purpose of assessing ✔️Ans - Establish a
database for client responses to his or her health
In the validating activity of the assessing phase of the nursing process, the
nurse performs which of the following ✔️Ans - Confirms data are
collected and accurate
A major characteristic of the nursing process is which of the following ✔️
Ans - A focus on client needs
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