Exam 5 NUR 215
What signs and symptoms will your patient have if they have fluid volume excess? -
answer-crackles
-high blood pressure
-swollen legs
-bounding pulse
-difficulty breathing
The nurse knows that the results of a fecal occult blood test can be inaccurate if:
A.The client has had an excessive intake of red meat
B.The client is menstruating
C.The client takes high doses of vitamin C
D.All of the above - answerD.All of the above
Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data,
the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years."
Which nursing diagnosis is most appropriate for the nurse to use in their plan of care?
A.Diarrhea
B.Constipation
C.Risk for Ineffective Therapeutic Regimen
D.Perceived Constipation - answerD.Perceived Constipation
You are caring for a patient with a colostomy. In order to provide safe care, you
understand that when irrigating a colostomy a proper fitting cone is needed to prevent:
A.Introducing air into the colon
B.Leaking the solution around the stoma
C.Administering the solution too rapidly
D.Introduction of bacteria from the stoma - answerB.Leaking the solution around the
stoma
The nurse is administering a blood transfusion to a patient in shock. After 30 min the
patient spikes a fever and reports chest pain. Their blood pressure falls suddenly and
they become tachycardic. What type of reaction is this patient experiencing? -
answerhemolytic
The nurse is assisting the client in caring for their ostomy. The client states, "Oh, this is
so disgusting. I'll never be able to touch this thing." The nurse's best response is:
A."I'm sure you will get used to taking care of it eventually."
B."Yes, it is pretty messy, so I'll take care of it for you today."
C."It sounds like you are really upset."
D."You sound very angry. Should I call the chaplain for you?" - answerB."Yes, it is pretty
messy, so I'll take care of it for you
, The female client states to the nurse, "I'm so distressed. It seems like every time I laugh
hard, I wet myself." The nurse knows that this condition is known as:
A.Stress incontinence
B.Urge incontinence
C.Functional incontinence
D.Unconscious incontinence - answerA.Stress incontinence
The nurse prepares to insert an indwelling urinary catheter. Which statement least
explains the reason for this intervention?
A.Empty your bladder prior to your procedure.
B.Treat your problem of leaking urine.
C.Obtain a sterile urine specimen for culture.
D.Measure the amount of urine left after you emptied your bladder. - answerB.Treat
your problem of leaking urine.
There is a 24-hr urine collection in process for a client. The unlicensed assistive
personnel (UAP) inadvertently empties one specimen into the toilet instead of the
collection "hat." The nurse should:
A.Continue with the collection of urine until the 24-hr time period is finished.
B.Make a note to the lab to inform them that one specimen was missed during the
collection.
C.Begin filling a new collection container and take both containers to the lab at the end
of the collection period.
D.Dispose of the urine already collected and begin an entirely new 24-hr collection. -
answerD.Dispose of the urine already collected and begin an entirely new 24-hr
collection.
The student nurse has earned "A's" in all of her prerequisite courses. For the first exam
in a nursing course, they earn a "D" and now feel that they may not be smart enough to
become a nurse. What type of "loss" is the student experiencing?
A.Actual
B.External
C.Physical
D.Perceived - answerD.Perceived
A young woman's fiancé died in a car accident one month prior to their wedding day.
Since his death, she has become sexually promiscuous. What type of grief, if any, is the
woman displaying?
A.Chronic
B.Disenfranchised
C.Masked
D.No grief - answerC.Masked
The nurse is having difficulty deciphering the medication prescription written by the
provider. What is the best strategy to clarify the information?
What signs and symptoms will your patient have if they have fluid volume excess? -
answer-crackles
-high blood pressure
-swollen legs
-bounding pulse
-difficulty breathing
The nurse knows that the results of a fecal occult blood test can be inaccurate if:
A.The client has had an excessive intake of red meat
B.The client is menstruating
C.The client takes high doses of vitamin C
D.All of the above - answerD.All of the above
Mrs. Addie is 70 years old. While the nurse is gathering admission assessment data,
the patient states, "I've taken a tablespoon of Milk of Magnesia every day for 3 years."
Which nursing diagnosis is most appropriate for the nurse to use in their plan of care?
A.Diarrhea
B.Constipation
C.Risk for Ineffective Therapeutic Regimen
D.Perceived Constipation - answerD.Perceived Constipation
You are caring for a patient with a colostomy. In order to provide safe care, you
understand that when irrigating a colostomy a proper fitting cone is needed to prevent:
A.Introducing air into the colon
B.Leaking the solution around the stoma
C.Administering the solution too rapidly
D.Introduction of bacteria from the stoma - answerB.Leaking the solution around the
stoma
The nurse is administering a blood transfusion to a patient in shock. After 30 min the
patient spikes a fever and reports chest pain. Their blood pressure falls suddenly and
they become tachycardic. What type of reaction is this patient experiencing? -
answerhemolytic
The nurse is assisting the client in caring for their ostomy. The client states, "Oh, this is
so disgusting. I'll never be able to touch this thing." The nurse's best response is:
A."I'm sure you will get used to taking care of it eventually."
B."Yes, it is pretty messy, so I'll take care of it for you today."
C."It sounds like you are really upset."
D."You sound very angry. Should I call the chaplain for you?" - answerB."Yes, it is pretty
messy, so I'll take care of it for you
, The female client states to the nurse, "I'm so distressed. It seems like every time I laugh
hard, I wet myself." The nurse knows that this condition is known as:
A.Stress incontinence
B.Urge incontinence
C.Functional incontinence
D.Unconscious incontinence - answerA.Stress incontinence
The nurse prepares to insert an indwelling urinary catheter. Which statement least
explains the reason for this intervention?
A.Empty your bladder prior to your procedure.
B.Treat your problem of leaking urine.
C.Obtain a sterile urine specimen for culture.
D.Measure the amount of urine left after you emptied your bladder. - answerB.Treat
your problem of leaking urine.
There is a 24-hr urine collection in process for a client. The unlicensed assistive
personnel (UAP) inadvertently empties one specimen into the toilet instead of the
collection "hat." The nurse should:
A.Continue with the collection of urine until the 24-hr time period is finished.
B.Make a note to the lab to inform them that one specimen was missed during the
collection.
C.Begin filling a new collection container and take both containers to the lab at the end
of the collection period.
D.Dispose of the urine already collected and begin an entirely new 24-hr collection. -
answerD.Dispose of the urine already collected and begin an entirely new 24-hr
collection.
The student nurse has earned "A's" in all of her prerequisite courses. For the first exam
in a nursing course, they earn a "D" and now feel that they may not be smart enough to
become a nurse. What type of "loss" is the student experiencing?
A.Actual
B.External
C.Physical
D.Perceived - answerD.Perceived
A young woman's fiancé died in a car accident one month prior to their wedding day.
Since his death, she has become sexually promiscuous. What type of grief, if any, is the
woman displaying?
A.Chronic
B.Disenfranchised
C.Masked
D.No grief - answerC.Masked
The nurse is having difficulty deciphering the medication prescription written by the
provider. What is the best strategy to clarify the information?
