Urinary elimination
Which of the following is NOT a characteristic assessed during a urinary assessment?
A. pH
B. Color
C. Amount
D. Clarity
A. pH
Rationale: pH level is often not included in basic evaluations.
Parenteral nutrition refers to the delivery of nutrient solutions into:
A. the mouth
B. the intestines
C. a vein
D. the stomach
C. a vein
Rationale: Parenteral nutrition bypasses the digestive system, delivering nutrients directly into the bloodstream via a vein.
A. to produce melanin to protect the skin
B. to detect and eliminate pathogens that penetrate the skin
C. to maintain skin moisture to protect the dermis
D. to provide structural support
B. to detect and eliminate pathogens that penetrate the skin
Rationale: Langerhans cells are immune cells that play a crucial role in detecting and responding to pathogens
A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
A "I drink two hot cups of coffee each morning."
B "I love to eat apples and black-eyed peas."
C "I take a prescribed opioid pain medication at bedtime."
D "I drink an average of 2,000 milliliters of water daily."
C. I take prescribed opioid pain medication at bedtime
Rationale: Opioids are known to cause constipation
The nurse is counseling a patient on sleep hygiene practices. Which food or drink, if selected by the patient prior to bedtime, indicates the teaching was effective?
A. Black tea
B. Hot chocolate
C. Vanilla ice cream
D. Decaffeinated coffee
C. Vanilla ice cream
rationale: Vanilla ice cream contains L-tryptophan, which aids in sleep. Selecting vanilla ice cream indicates the teaching was effective. Black tea and hot chocolate contain caffeine that hinders sleep. Decaffeinated coffee retains some caffeine and is as such less appropriate than vanilla ice cream.
What is the approximate volume of blood filtered by the kidneys to produce urine?
A. 50-70 quarts
B. 200-250 quarts
C. 120-150 quarts
D. 80-100 quarts
C. 120-150 quarts
Rationale: The kidneys filter about 120 to 150 quarts of blood daily to produce urine. 200 to 250 quarts exceeds the actual physiological capacity of the kidneys.
Describe how food allergies and food intolerances differ in terms of their effects on the body.
A. Food allergies lead to gastrointestinal issues, while food intolerances lead to an immune response
B. Food allergies lead to an immune response, while food intolerances lead to gastrointestinal issues
C. Both cause immune responses
D. They don't have significant differences
B. Food allergies lead to an immune response, while food intolerances lead to gastrointestinal issues
Rationale: food allergies provoke an immune response, while intolerances primarily result in gastrointestinal discomfort.
What is the primary reason for practicing effective handwashing in healthcare settings?
A. improve patient comfort
B. reduce the need for PPE
C. prevent HAIs (healthcare associated infections)
D. enhance the skin's defenses
C. prevent HAIs
rationale: The primary goal of effective handwashing is to prevent healthcare-associated infections (HAIs), not to improve comfort or skin appearance. While PPE is important, hand hygiene is the most critical measure for infection control, directly impacting patient safety and health outcomes.
The 82-year-old patient has voided 240 mL in a 24-hour period. Which term does the nurse use to report this finding?
A. Oliguria
B. Anuria
C. Enuresis
D. Dysuria
A. Oliguria
Rationale
Oliguria is commonly defined by less than 400 mL/day in an adult. It is one of the clinical characteristics of acute kidney injury. Anuria is described as less than 50 mL/day. Dysuria is a term referring to painful voiding, and enuresis is the medical term for bedwetting.
The registered nurse is providing an inservice on recognizing urinary tract infections (UTI) in older adults for the staff of the long-term care facility. The nurse reminds the staff to be vigilant for which symptom, which may be the only indicator of a UTI in the older adult patient?
A. Fever
B. Nocturia
C. Referred pain
D. Acute confusion
D. Acute confusion
rationale: Acute confusion is often the only symptom exhibited by older adults when experiencing urinary tract infections. Fever may occur if the infection becomes severe. Nocturia, or waking during the night to void, is not a symptom specific to infection. Referred pain may occur if the infection becomes severe.
What is the maximum volume the bladder can hold?
A. Up to 2 cups
B. Up to 1 cup
C. Up to 3 cups
D. Up to 4 cups
A. Up to 2 cups
Describe how gastric decompression contributes to patient safety during nutritional support.
A. Gastric decompression promotes faster digestion
B. Gastric decompression removes excess gas from the stomach
C. Gastric decompression removes gas from the large intestine
D. Gastric decompression helps the body absorb more nutrients
B. Gastric decompression removes gas from the stomach
Rationale: gastric decompression primarily focuses on preventing aspiration and alleviating stomach pressure, not directly on nutrient absorption. While it may indirectly support absorption, its main role is enhancing patient safety by managing gastric contents.
What is a common skin condition that bariatric clients may face due to their body structure?
A. deep skin folds
B. dry skin
C. psoriasis
D. eczema
A. deep skin folds
rationale: Deep skin folds are common in bariatric clients due to excess weight, leading to friction and moisture retention, which can cause skin issues.
Which finding is expected in the patient with diabetic ketoacidosis (DKA)?
A. pH = 7.52
B. Sodium = 153 mEq/dL
C. Bicarbonate = 13.4 mEq/dL
D. Urine output = 0.33 mL/kg/h
C. Bicarbonate = 13.4 mEq/dL
Rationale: A person with diabetic ketoacidosis (DKA) will typically have a plasma bicarbonate level lower than 15mEq/L and an arterial pH lower than 7.35. Polyuria, not oliguria (< 1 mL/kg/h) will be present. The patient will likely be hyponatremic, not hypernatremic.
A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply.
a. A 78-year-old male patient diagnosed with an enlarged prostate
b. An 83-year-old female patient who is on bedrest
c. A 75-year-old female patient who is diagnosed with vaginal prolapse
d. An 89-year-old male patient who has dementia
e. A 73-year-old female patient who is taking antihistamines to treat allergies
f. A 90-year-old male patient who has difficulty walking to the bathroom
a, c, e.
rationale: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.
The patient undergoing continuous bladder irrigation (CBI) following a prostatectomy reports an extreme need to urinate. Which action by the nurse is most appropriate?
A. Partially deflate the catheter retention balloon and advance the catheter
B. Assess the CBI system for kinks or obstruction and determine the intake and output
C. Provide the patient with a book or television show to encourage distraction and redirection
D. Ensure there is no tension on the catheter by instructing the patient to bend the knees in bed
B. Assess the CBI system for kinks or obstruction and determine the intake and output.
Rationale: During continuous bladder irrigation, it is common for the patient to report a continuous need to urinate. It is likely the patient simply needs to focus on something else such as a book or TV show, however, the nurse must first assess the CBI system for kinks or obstruction and determine the intake and output. If the system is determined to be working properly, the patient can be redirected. Manipulation of the catheter in anyway (deflating the balloon, advancing the catheter or releasing tension on the catheter) is contraindicated and must only be performed by the provider
A patient has been diagnosed with esophageal cancer and is unable to eat solid food. What nutritional support method would be most appropriate for this patient?
A. Enteral nutrition
B. Regular diet
C. Parenteral nutrition
D. Oral nutritional supplements
A. Enteral nutrition
Rationale: Enteral nutrition provides necessary nutrients directly to the stomach or intestines, ensuring adequate intake while bypassing the need for solid food.
What is an early sign of dementia?
A. enhanced social interactions
B. difficulty performing hygiene tasks
C. increased appetite
D. performs hygiene tasks on a schedule
B. difficulty performing hygiene tasks
rationale: dementia often leads to challenges in daily tasks, including personal hygiene. The incorrect options, like improved memory and enhanced social interactions, are misleading as they suggest positive changes, which are not typical in dementia progression.
Two days after receiving a kidney transplant, the patient complains of flank pain. Which urine output, if reported by the unlicensed assistive personnel, is most concerning to the nurse?
A. 10 mL/hour
B. 50 mL/hour
C. 80 mL/hour
D. 150 mL/hour
A. 10 mL/hr
Rationale:
Common complications of kidney transplant include pyelonephritis as well as bladder and ureteral obstructions. Typically, the normal urine output is 1 ml/kg/hour. A 10 mL/hour urine output should alert the nurse that the patient may be experiencing bladder or ureteral stenosis (obstruction). The nurse must report it to the physician for further evaluation and immediate treatment. A 50-100 mL/hour urinary output are within normal limits. A rate of 150 mL/hour is less concerning than oliguria.
Which of the following is considered a normal body mass index (BMI)?
A. 18.5 - 24.9
B. 16.9-22.9
C. 22.9 - 30.5
D. 26.5-32.9
A. 18.5-24.9
rationale: Normal BMI is considered to be 18.5 - 24.9. A BMI below that would indicate that the individual is underweight, while a higher value may indicate that the individual is overweight.
What is another name for urge incontinence?
A. Urge incontinence
B. Stress incontinence
C. Overactive bladder
D. Physical incontinence
C. Overactive bladder
Rationale: Stress incontinence occurs when physical pressure causes leakage, while urge incontinence, or overactive bladder, involves a sudden, intense urge to urinate.
What does monitoring intake and output help assess in a client?
A. Medication adherence
B. Fluid status
C. UTI symptoms
D. Nutritional status
B. Fluid status
Rationale: Monitoring intake and output primarily evaluates a client's hydration levels, as it tracks fluid and consumption.
What is the definition of a partial bed bath in nursing practice?
A. Nurse assists patient with bathing
B. Patient does bathing on own
C. Patient is bathed in bed instead of in a tub
D. Nurse bathes the patient
A. Nurse assists patient with bathing
Rationale: The correct definition emphasizes the collaborative nature of a partial bed bath, where the client participates actively while receiving assistance. The incorrect options misinterpret this by suggesting a full-body wash, tub bathing, or complete self-bathing, which do not accurately reflect the concept of partial assistance.
The nurse asks a patient to provide a urine sample for a urine culture. When the nurse returns 3 hours later, the patient says the urine sample has been sitting by the bed for the last 2 hours. Which action by the nurse is appropriate?
A. Send it to the laboratory immediately
B. Dump the sample and ask the patient to provide a fresh specimen
C. Refrigerate the sample
D. Carry the sample to the laboratory by hand
B. dump the sample and ask the patient to provide a fresh specimen
Rationale: A urine sample that has been at room temperature for more than one hour should be discarded and a fresh sample obtained. Laboratory tests on such a sample may give inaccurate results due to bacterial growth and chemical reactions with the air. Refrigerating the sample is helpful soon after it is obtained, but will not do any good at this point. Sending an old sample to the lab or carrying it by hand will both lead to inaccurate results.
A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply.
a. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis.
b. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up.
c. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter.
d. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture.
e. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma.
f. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.
d, e, f.
Rationale: A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.