Bowel Elimination
A nurse is caring for a patient with a new colostomy. Which assessment finding should the nurse report immediately to the healthcare provider?
A. Pink, moist stoma
B. Small amount of mucus in the stool
C. Purple, dusky stoma
D. Loose stools
Correct Answer: C. Purple, dusky stoma
Rationale:
A dusky or purple stoma indicates compromised blood flow and is a medical emergency. A healthy stoma should be pink or red and moist. Mucus and loose stools can be normal depending on the type of colostomy.
1. A nurse is caring for a patient who is experiencing acute urinary retention. Which intervention is the priority?
**Correct Answer:** C. Catheterize the patient immediately
3. A patient has a surgical incision closed with staples and healing without complications. What type of wound healing is this?
**Correct Answer:** A. Primary intention
**Rationale:** Primary intention healing occurs when wound edges are approximated using staples, sutures, or glue, typically with minimal tissue loss.
2. What is the most effective method for preventing the spread of health care–associated infections (HAIs)?
**Correct Answer:** C. Proper hand hygiene
**Rationale:** Hand hygiene is the single most effective way to prevent the transmission of infectious agents in healthcare settings.
The nurse is reviewing IV fluid options for patients with fluid imbalances. Which of the following are examples of isotonic saline solutions that may be used to treat fluid volume deficit?
Select all that apply.
A. 0.9% Sodium Chloride (Normal Saline)
B. 3% Sodium Chloride
C. Lactated Ringer’s solution
D. 0.45% Sodium Chloride
E. D5W (5% Dextrose in Water) – initially
F. 0.33% Sodium Chloride
Correct Answers:
✅ A. 0.9% Sodium Chloride (Normal Saline)
✅ C. Lactated Ringer’s solution
✅ E. D5W (5% Dextrose in Water) – initially
Rationale:
A: Normal saline is isotonic, often used for fluid volume replacement.
B: Incorrect – 3% saline is hypertonic, used cautiously for severe hyponatremia.
C: Lactated Ringer’s is isotonic and used for fluid resuscitation.
D & F: Incorrect – 0.45% and 0.33% saline are hypotonic solutions.
E: D5W is isotonic in the bag, but becomes hypotonic once metabolized; it's often initially used to expand volume.
5. Which of the following is considered the last resort for managing severe constipation?
**Correct Answer:** B. Digital removal of stool
**Rationale:** Digital removal is invasive and used only when other measures fail, due to discomfort and potential complications.
2. Which of the following is a risk associated with permanent catheterization for chronic urinary retention?
**Correct Answer:** C. Urosepsis
6. Which stage of pressure ulcer is characterized by full-thickness skin loss with visible subcutaneous fat, but no bone, tendon, or muscle exposure?
**Correct Answer:** C. Stage 3
**Rationale:** Stage 3 pressure ulcers involve full-thickness tissue loss with visible subcutaneous fat, but without exposure of muscle or bone.
5. A patient has a protozoan infection. Which type of medication would the nurse expect to be prescribed?
**Correct Answer:** B. Antimicrobial
**Rationale:** Protozoan infections are treated with antimicrobial agents that target parasitic organisms.
A nurse is caring for a hospitalized patient who reports difficulty sleeping, irritability, and reduced attention span. The patient has been in a noisy, brightly lit room near the nurses’ station. Which nursing action is the priority to improve the patient’s condition?
A. Offer the patient a cup of warm milk before bedtime
B. Administer a prescribed PRN sedative
C. Move the patient to a quieter room with dim lighting
D. Encourage the patient to take a short walk before bed
Correct Answer: C. Move the patient to a quieter room with dim lighting
Rationale:
C is correct: Sensory overload due to constant noise and light is contributing to sleep deprivation and irritability. Reducing sensory input promotes restful sleep and prevents complications such as delirium.
A is a supportive action but doesn’t address the environmental cause.
B is not the first-line intervention and may mask the underlying problem.
D may be helpful, but doesn’t address the environmental sensory overload disrupting sleep.
A nurse is preparing to administer a cleansing enema to a patient. Which of the following actions by the nurse requires intervention?
A. Explaining the procedure and positioning the patient in left lateral position
B. Wearing clean gloves during the procedure
C. Using sterile technique to prepare the enema
D. Instructing the patient to retain the solution for as long as possible
Correct Answer: C. Using sterile technique to prepare the enema
Rationale:
Sterile technique is unnecessary for enema administration; clean gloves and aseptic technique are sufficient. The left lateral position facilitates flow of solution into the sigmoid colon. Retaining the solution helps maximize the enema’s effectiveness.
3. A patient with urinary incontinence is prescribed oxybutynin (Ditropan). What is the primary action of this medication?
**Correct Answer:** B. Reduces bladder spasticity
A nurse is assessing a hospitalized patient for risk of developing pressure ulcers. Which of the following patients is at greatest risk?
A. A 70-year-old with a Braden Scale score of 21 who ambulates with assistance
B. A 50-year-old post-op patient who is alert and mobile
C. A 92-year-old with limited mobility, incontinence, and a Braden score of 12
D. A 65-year-old with stable vital signs and a healing abdominal wound
Correct Answer: C. A 92-year-old with limited mobility, incontinence, and a Braden score of 12
Rationale:
A Braden Scale score below 18 indicates high risk. This patient also has additional risk factors—advanced age, immobility, and incontinence—all contributing to pressure ulcer development. The others have fewer risk factors or higher Braden scores.
A nurse is monitoring a patient for early signs of infection. Which of the following findings should the nurse report immediately?
A. Warm, pink surgical incision with mild tenderness
B. Nasal congestion and mild sore throat
C. Burning sensation during urination and foul-smelling urine
D. Slight increase in appetite and energy
Correct Answer: C. Burning sensation during urination and foul-smelling urine
Rationale:
Burning with urination and foul-smelling urine are signs of a possible urinary tract infection. This should be reported promptly to prevent worsening or systemic spread. The other options either reflect expected or non-urgent conditions.
The nurse is assessing a patient for sleep deprivation related to sensory overload. Which of the following findings would support this nursing diagnosis?
Select all that apply.
A. Difficulty concentrating and forgetfulness
B. Falling asleep easily during conversations
C. Elevated pain tolerance
D. Irritability and mood swings
E. Reports of frequent nighttime awakenings
F. Hypoactive reflexes and deep sedation
Correct Answers:
✅ A. Difficulty concentrating and forgetfulness
✅ B. Falling asleep easily during conversations
✅ D. Irritability and mood swings
✅ E. Reports of frequent nighttime awakenings
Rationale:
A: Sleep deprivation commonly causes decreased cognitive function.
B: Excessive daytime sleepiness is a hallmark of sleep deprivation.
C: Incorrect – Pain tolerance is often lower, not higher, with poor sleep.
D: Mood disturbances are expected with lack of rest.
E: Nighttime sleep interruptions are key indicators of sleep deprivation.
F: Incorrect – Hypoactive reflexes and deep sedation are not typical signs; rather, patients are often restless or hyperalert from poor-quality sleep.
A nurse is educating a patient who has a new ileostomy. Which patient statement indicates a need for further teaching?
A. "I will measure and record my intake and output daily."
B. "I will monitor the color of my stoma regularly."
C. "My stool will be solid and formed."
Correct Answer: C. "My stool will be solid and formed."
Rationale:
Stool from an ileostomy is typically liquid or semi-liquid because it bypasses the colon. A solid, formed stool is expected with a colostomy, not an ileostomy. The other statements reflect accurate understanding of ileostomy care.
1. A nurse is caring for a patient who is experiencing acute urinary retention. Which intervention is the priority?
**Correct Answer:** C. Catheterize the patient immediately
**Rationale:** Acute urinary retention can lead to bladder overdistention and damage; immediate catheterization is necessary to relieve retention.
A patient has a surgical wound closed with staples and minimal tissue loss. The nurse understands this wound will most likely heal by:
A. Secondary intention
B. Tertiary intention
C. Granulation intention
D. Primary intention
Correct Answer: D. Primary intention
Rationale:
Primary intention healing occurs in wounds with minimal tissue loss where edges are approximated (e.g., closed with staples or sutures). It has a shorter healing time, less scarring, and lower risk of infection compared to secondary or tertiary intention.
The nurse is assessing a patient for possible infection. Which of the following findings are commonly associated with infection?
Select all that apply.
A. Fever and chills
B. Stiff neck
C. Decreased white blood cell (WBC) count
D. Redness and swelling at wound site
E. Vomiting and diarrhea
F. Increased energy and appetite
Correct Answers:
✅ A. Fever and chills
✅ B. Stiff neck
✅ D. Redness and swelling at wound site
✅ E. Vomiting and diarrhea
Rationale:
A: Fever and chills are classic signs of infection.
B: Stiff neck may indicate serious infections like meningitis.
C: Incorrect – Infection typically causes an increase in WBC count, not a decrease.
D: Redness and swelling are signs of localized inflammation/infection.
E: GI symptoms are common with infections, especially viral or foodborne.
F: Incorrect – Infection usually causes fatigue and loss of appetite, not increased energy.
A nurse is caring for an older adult patient recently diagnosed with bilateral sensorineural hearing loss. The patient appears withdrawn and avoids group activities. Which nursing action is most appropriate to support this patient’s psychosocial and sensory needs?
A. Encourage the patient to use hearing aids during social interactions
B. Reassure the patient that hearing loss is a normal part of aging
C. Speak louder and directly into the patient’s ear when giving instructions
D. Recommend limiting social activities to reduce frustration
Correct Answer: A. Encourage the patient to use hearing aids during social interactions
A is correct: Using hearing aids promotes communication, independence, and social engagement, directly addressing both sensory and psychosocial concerns.
B is incorrect: While age-related hearing loss is common, normalization alone does not support effective adaptation or address the impact.
C is incorrect: Speaking louder may distort sound; it’s more effective to speak clearly and face the patient, not directly into the ear.
D is incorrect: Avoiding social activities can worsen isolation and depression.
The nurse is developing a care plan for a patient with both urinary incontinence and chronic constipation. Which of the following interventions should the nurse include?
Select all that apply.
A. Encourage a toileting schedule every 2 hours
B. Apply a condom catheter continuously
C. Increase fiber and fluid intake as tolerated
D. Administer anticholinergic medications routinely
E. Promote regular physical activity
F. Use skin barrier creams to maintain skin integrity
Correct Answers:
✅ A. Encourage a toileting schedule every 2 hours
✅ C. Increase fiber and fluid intake as tolerated
✅ E. Promote regular physical activity
✅ F. Use skin barrier creams to maintain skin integrity
Rationale:
A: Scheduled toileting helps manage both urinary incontinence and prevent constipation.
C: Fiber and fluids help soften stool and promote bowel movements.
E: Physical activity stimulates bowel motility and supports urinary health.
F: Barrier creams protect skin from moisture-related breakdown due to incontinence.
B: Condom catheters may be used but not continuously or without assessing appropriateness.
D: Anticholinergics can worsen constipation and are not routine unless specifically indicated.
The nurse is caring for a patient with chronic urinary retention. Which nursing interventions are appropriate for managing this condition?
Select all that apply.
A. Teach the patient to perform the Crede’s maneuver
B. Encourage double voiding to empty the bladder completely
C. Limit fluid intake to reduce bladder distention
D. Educate on intermittent self-catheterization
E. Monitor for signs of urinary tract infection
F. Administer anticholinergic medications to improve bladder tone
Correct Answers:
✅ A. Teach the patient to perform the Crede’s maneuver
✅ B. Encourage double voiding to empty the bladder completely
✅ D. Educate on intermittent self-catheterization
✅ E. Monitor for signs of urinary tract infection
Rationale:
A: The Crede’s maneuver (manual pressure over the bladder) helps promote bladder emptying in some patients.
B: Double voiding is a useful technique for chronic retention.
D: Intermittent self-catheterization reduces infection risk and helps with regular bladder emptying.
E: Patients with retention are at high risk for UTIs and should be monitored.
C: Limiting fluids can lead to dehydration and concentrated urine, worsening urinary issues.
F: Anticholinergic medications worsen retention by relaxing the bladder muscle and are contraindicated.
The nurse is teaching a group of students about the characteristics of wounds that heal by secondary intention. Which of the following statements should be included in the teaching?
Select all that apply.
A. The wound edges are well approximated.
B. Healing involves significant tissue loss.
C. The risk of infection is higher than in primary intention.
D. Scarring is minimal and often unnoticeable.
E. Wound contraction and granulation tissue formation are part of the process.
F. Healing time is generally longer than primary intention wounds.
Correct Answers:
✅ B. Healing involves significant tissue loss
✅ C. The risk of infection is higher than in primary intention
✅ E. Wound contraction and granulation tissue formation are part of the process
✅ F. Healing time is generally longer than primary intention wounds
Rationale:
A: Incorrect – Secondary intention wounds do not have approximated edges.
B: Correct – These wounds involve more tissue loss.
C: Correct – More open area = higher infection risk.
D: Incorrect – Scarring is usually greater with secondary intention.
E: Correct – Healing relies on granulation tissue to fill the wound.
F: Correct – Healing takes longer due to tissue regeneration and open exposure.
The nurse is educating a group of nursing students about infection prevention in healthcare settings. Which of the following are appropriate strategies to reduce the risk of infection?
Select all that apply.
A. Perform hand hygiene before and after patient contact
B. Use sterile gloves for every patient encounter
C. Follow cough etiquette, including covering mouth and nose when sneezing
D. Administer antibiotics to all patients as a preventive measure
E. Disinfect equipment and surfaces between patient use
F. Avoid using personal protective equipment (PPE) unless visibly necessary
Correct Answers:
✅ A. Perform hand hygiene before and after patient contact
✅ C. Follow cough etiquette, including covering mouth and nose when sneezing
✅ E. Disinfect equipment and surfaces between patient use
Rationale:
A: Hand hygiene is the most effective method to prevent the spread of infection.
B: Incorrect – Sterile gloves are only necessary for sterile procedures, not routine care.
C: Cough etiquette helps prevent respiratory infections from spreading.
D: Incorrect – Routine prophylactic antibiotics are not recommended due to resistance risk.
E: Cleaning equipment between patients prevents cross-contamination.
F: Incorrect – PPE should be used based on the level of exposure risk, not just visible signs.
A nurse is caring for a patient who recently underwent a thyroidectomy. The patient reports tingling in the lips and fingers, and the nurse observes a positive Chvostek’s sign. Which additional assessment finding would most strongly support a diagnosis of hypocalcemia?
A. Bradycardia and bounding peripheral pulses
B. Generalized muscle weakness with decreased deep tendon reflexes
C. Laryngospasms and stridor with increased neuromuscular excitability
D. Constipation and hypoactive bowel sounds
Correct Answer: C. Laryngospasms and stridor with increased neuromuscular excitability