Urinary Elimination
Which finding indicates urinary retention?
A. Flat abdomen
B. Suprapubic distention
C. Hyperactive bowel sounds
D. Frequent small stools
B. Suprapubic distention
A client with chronic constipation asks how to promote regular bowel movements. Which instruction should the nurse include?
A. “Limit your fluid intake to prevent bloating.”
B. “Increase your intake of whole grains and fresh fruits.”
C. “Avoid physical activity after meals.”
D. “Use a stimulant laxative every day.”
B. “Increase your intake of whole grains and fresh fruits.”
A client has a BMI of 18.0 kg/m². How should the nurse interpret this value?
A. Underweight
B. Normal weight
C. Overweight
D. Obesity
A. Underweight
A nurse is caring for a client with fluid volume deficit. Which IV fluid is most appropriate for initial treatment?
A. 0.9% normal saline
B. 3% hypertonic saline
C. D5W
D. 0.45% normal saline
A. 0.9% normal saline
A nurse evaluates a client receiving diuretics for fluid volume overload. Which finding indicates the therapy is effective?
A. Weight decreases 3 pounds in 24 hours
B. Crackles persist in both lower lung fields
C. Blood pressure increases to 160/98 mm Hg
D. Urine output decreases to 20 mL/hr
A. Weight decreases 3 pounds in 24 hours
A nurse is assessing a client who reports involuntary urine loss when coughing, laughing, or exercising. Which type of urinary incontinence should the nurse suspect?
A. Urge incontinence
B. Overflow incontinence
C. Stress incontinence
D. Reflex incontinence
C. Stress incontinence
A nurse is assessing a client with suspected fecal impaction. Which finding is most consistent with this condition?
A. Frequent small liquid stools
B. Absent bowel sounds
C. Severe abdominal rigidity
D. High‑volume formed stools
A. Frequent small liquid stools
A nurse is assessing a client for malnutrition. Which finding is most concerning?
A. Decreased prealbumin
B. Normal hemoglobin
C. Normal sodium
D. Normal albumin
A. Decreased prealbumin
A client with vomiting for 24 hours is being evaluated for dehydration. Which laboratory value is most consistent with fluid volume deficit?
A. Urine specific gravity 1.035
B. Hematocrit 32%
C. Sodium 135 mEq/L
D. BUN 10 mg/dL
A. Urine specific gravity 1.035
A client with fluid volume overload is being discharged with instructions to monitor daily weight. Which statement indicates the client understands the teaching?
A. “I will weigh myself after breakfast each day.”
B. “I should weigh myself at different times to compare changes.”
C. “I will weigh myself every morning using the same scale.”
D. “I only need to weigh myself if I feel swollen.”
C. “I will weigh myself every morning using the same scale.”
A nurse is caring for a client with benign prostatic hyperplasia (BPH). Which assessment finding is most consistent with this condition?
A. Continuous urinary dribbling
B. Sudden, strong urge to void
C. Large amounts of urine with each void
D. High‑volume urinary output
A. Continuous urinary dribbling
A client is prescribed a stool softener. Which outcome indicates the medication is effective?
A. The client reports decreased abdominal pain
B. The client passes soft, formed stool without straining
C. The client has a bowel movement every 3 days
D. The client reports increased gas and bloating
B. The client passes soft, formed stool without straining
A nurse is reinforcing teaching for a client with celiac disease. Which meal selection indicates the need for further teaching?
A. Grilled chicken with steamed vegetables
B. Baked potato with sour cream
C. Barley vegetable soup
D. Rice noodles with stir‑fried vegetables
C. Barley vegetable soup
A nurse evaluates a client who received IV fluids for hypovolemia. Which finding indicates the need for further intervention?
A. Weight increases by 1 pound
B. Blood pressure remains at 92/60 mm Hg
C. Urine output increases to 35 mL/hr
D. Heart rate decreases to 92/min
B. Blood pressure remains at 92/60 mm Hg
A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with fluid volume overload who has 2+ pitting edema in the ankles
B. A client with fluid volume overload reporting increased shortness of breath
C. A client with fluid volume overload who gained 1 pound overnight
D. A client with fluid volume overload receiving furosemide with urine output of 30 mL/hr
B. A client with fluid volume overload reporting increased shortness of breath
A client presents to the emergency department with severe flank pain that radiates to the groin, nausea, and restlessness. The nurse notes hematuria on urinalysis. Which priority nursing action should the nurse take?
A. Encourage the client to restrict fluid intake
B. Apply a cold compress to the flank area
C. Strain all urine for stone fragments
D. Insert an indwelling urinary catheter
C. Strain all urine for stone fragments
A nurse is teaching a client about appropriate management strategies for acute diarrhea. Which interventions should the nurse include in the teaching? (Select all that apply.)
A. Increase oral fluid intake to prevent dehydration
B. Consume electrolyte‑rich solutions as tolerated
C. Take loperamide as directed for acute symptoms
D. Follow a high‑fiber diet until stools normalize
E. Avoid caffeine and high‑sugar beverages
A. Increase oral fluid intake to prevent dehydration
B. Consume electrolyte‑rich solutions as tolerated
C. Take loperamide as directed for acute symptoms
E. Avoid caffeine and high‑sugar beverages
A nurse is teaching a client with obesity about portion control. Which statement indicates understanding?
A. “I will use smaller plates to help reduce portions.”
B. “I should skip breakfast to reduce calories.”
C. “I will eliminate all snacks.”
D. “I should avoid all carbohydrates.”
A. “I will use smaller plates to help reduce portions.”
A client with fluid volume deficit is receiving IV fluids. Which outcome indicates improvement?
A. Urine output 15 mL/hr
B. Heart rate decreases from 120 to 88/min
C. Blood pressure decreases further
D. Urine specific gravity increases
B. Heart rate decreases from 120 to 88/min
A client with fluid volume overload is on a sodium‑restricted diet. Which finding indicates the client needs further teaching?
A. Weight decreases by 1 pound
B. The client reports avoiding canned soups
C. The client chooses deli meats for lunch
D. Edema decreases in the lower extremities
C. The client chooses deli meats for lunch
A nurse is teaching a client with recurrent renal calculi about prevention strategies. Which statement indicates understanding? (Select all that apply.)
A. “I will increase my fluid intake each day.”
B. “I should limit foods high in calcium.”
C. “I will reduce my intake of high‑oxalate foods.”
D. “I should avoid all physical activity.”
E. “I will report any flank pain immediately.”
A. “I will increase my fluid intake each day.”
C. “I will reduce my intake of high‑oxalate foods.”
E. “I will report any flank pain immediately.”
A nurse is teaching a client about factors that can contribute to constipation. Which of the following should the nurse include as potential causes? (Select all that apply.)
A. Low fluid intake
B. Opioid analgesic use
C. High‑fiber diet
D. Decreased physical activity
E. Ignoring the urge to defecate
A. Low fluid intake
B. Opioid analgesic use
C. High‑fiber diet
E. Ignoring the urge to defecate
A nurse is teaching a client about strategies to promote healthy nutrition and prevent chronic disease. Which recommendations should the nurse include? (Select all that apply.)
A. Choose whole grains instead of refined grains
B. Increase intake of fruits and vegetables
C. Limit saturated and trans fats
D. Consume sugary beverages to maintain energy
E. Reduce sodium intake to support heart health
A. Choose whole grains instead of refined grains
B. Increase intake of fruits and vegetables
C. Limit saturated and trans fats
E. Reduce sodium intake to support heart health
A nurse is assessing a client for fluid volume deficit. Which findings should the nurse expect? (Select all that apply.)
A. Increased urine specific gravity
B. Hypotension
C. Bounding peripheral pulses
D. Dry mucous membranes
E. Weight gain
A. Increased urine specific gravity
B. Hypotension
D. Dry mucous membranes
A nurse is assessing a client suspected of having fluid volume overload. Which clinical manifestations should the nurse expect? (Select all that apply.)
A. Crackles in the lung bases
B. Bounding peripheral pulses
C. Jugular vein distention
D. Hypotension
E. Weight gain
A. Crackles in the lung bases
B. Bounding peripheral pulses
C. Jugular vein distention
E. Weight gain