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NUR 325 Exam 2 Review Questions
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NUR 325 Exam 2 Review Questions/NUR 325 Exam 2 Review Questions/NUR 325 Exam 2 Review Questions
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NUR 325 Exam 2 Review Questions Which of the following health conditions would be LEAST likely to cause fluid and electrolyte imbalances? a. Vomiting and diarrhea b. Breaking a leg c. Renal failure d. Congestive heart failure (CHF) - correct answer B Which of the following group of symptoms would trigger you to think there may be some fluid and electrolyte imbalances in your patient? a. Tinnitus, erythema, shortness of breath b. Petechiae, fever, low blood pressure c. Unexplained nausea, dizziness, edema d. Tachycardia, drowsiness, nausea - correct answer C The patient talks with the nurse about bladder health. What is one of the most important recommendations the nurse can make for this patient? a. Eat foods high in fiber. b. Drink 6 to 8 glasses of noncaffeinated fluids daily. c. Exercise in the morning and evening. d. Visit the urologist once yearly. - correct answer B (Drinking 6 to 8 glasses of noncaffeinated fluids daily helps with bladder health because urine is not stagnating in the bladder. Exercising and eating foods hig h in fiber help with bowel elimination but do not have an effect on urination. Visiting the urologist is good if there is a problem, but this is not the most important recommendation from the nurse.) NUR 325 Exam 2 Review Questions The nurse is caring for a confused patient who is wearin g a vest restraint in bed. The nurse speaks with an unlicensed assistant about toileting the patient. The nurse knows the unlicensed assistant understands the toileting procedure when making which statement? a. The patient must remain in the restraints al l day. b. The patient needs to be toileted to maintain a regular toileting schedule. c. The patient needs to be provided with adult briefs for incontinence. d. The patient will use the call bell when he or she feels the urge to void. - correct answer B (Th e correct answer is toileting the patient so he or she can maintain a normal toileting schedule. Leaving the patient in restraints all day is against the standard of care. Providing the patient with briefs when he or she is not incontinent does not meet th e patient's toileting needs. If the patient is confused, he or she will not be able to use the call bell.) 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 answer 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. Th is 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 infect ions in the future. The nurse should make which appropriate recommendations for the patient? (Select all that apply.) NUR 325 Exam 2 Review Questions 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 answer 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 urina ry 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 d. Dark amber urine - correct answer 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.) Wha t 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 answer 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 NUR 325 Exam 2 Review Questions advancement of the catheter until flows and then inserting ¼ inch more is not unique to the ma le 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 answer 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 i s 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. 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 answer 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 vo iding as possible. Suprapubic tenderness and pain are possible indicators of urinary retention and/or a UTI.)The benefits of buying summaries with Stuvia:
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