A nurse is assessing a client with diarrhea. During physical examination, the nurse inspects the
abdomen. Which of the following would the nurse perform next? - Answers Auscultation
When a client is diagnosed with a urinary tract infection, the nurse anticipates that the client's urine
will be - Answers Cloudy with an offensive odor
A nurse is caring for a client with primary constipation. Which of the following factors is responsible
for primary constipation? - Answers Inadequate intake of liquid
Primary constipation results from lifestyle factors such as insufficient fluid intake, inadequate intake
of fiber, inactivity, or ignoring the urge to defecate.
A patient with terminal cancer is taking high doses of a narcotic for pain. The nurse will teach the
patient or family about what common side effect of opioids? - Answers Constipation
Narcotics decrease gastrointestinal motility, resulting in constipation.
Upon assessment of the urine in a patient's indwelling urinary catheter drain bag, the nurse notes the
urine to be dark yellow. This assessment finding indicates which of the following? - Answers The
patient is underhydrated.
Urinary catheterization is the most common cause of hospital acquired infection.
True/False - Answers True
You are attempting to insert a urinary catheter into a female patient's bladder and realize the
catheter has been inserted into the vagina. Which of the following actions is most appropriate? -
Answers Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly
above the misplaced catheter.
When educating an elderly client on the prevention of constipation, the nurse should provide which
of the following educational interventions? - Answers Increase intake of fresh vegetables
Educating older persons to recognize that decreased frequency of bowel movements is usually a
normal result of aging. Nurses should encourage a change in dietary habits to increase the amount of
fluids and high-fiber foods in the diet and to increase activity to prevent constipation.
Besides using the medical records, which form of communication should the nurse use to provide
client details to the health care team coming on duty in the next shift? - Answers Change of shift
reports
A change of shift report is a discussion between health care team members leaving their shift and
health care team members coming on duty for the next shift. It includes a summary of each client's
condition and current status of care.
A client will be transferred from the surgical unit to the rehabilitation unit for further care. Which of
the following would the nurse expect to include when preparing the verbal handoff report? - Answers
Current client assessment
When taking a telephone order from a physician, the nurse verifies that he or she understands the
order by: - Answers Repeating the order back to the physician.
A nurse at a health care facility has just reported for duty. Which of the following should the nurse do
to ensure maximum efficiency of change-of-shift reports? - Answers Come prepared with material
required to take notes.
A nurse is requesting to receive change of shift report at the bedside of each client. The nurse giving
the report asks about the purpose of giving report at the bedside. Which response by the nurse
receiving report is most appropriate? - Answers "It will allow for us to see the client and possibly
increase client participation in care."
The nurse should utilize ISBARR communication (Introduction, Situation, Background, Assessment,
Recommendation, Read Back) during which of the following clinical situations? - Answers When
communicating a client's change in condition to the client's physician
The sharing of information about a client is - Answers Reporting
A nurse is caring for a client with severe lower back pain. The doctor orders administration of an
analgesic as a stat dose. When should the nurse administer the medication? - Answers Immediately