NUR 330 Exam #4 NCLEX Questions With Complete
Solutions
1. You are assigned four patients on your nursing unit. Which
patient is at most risk for pressure ulcers?
A) A 72 year old female weighing 82lbs with stress incontinence
and dementia.
B) A 90 year old male with Congestive Heart Failure who has
3+ pitting edema in lower extremities.
C) A 6 month old with the flu.
D) An ambulatory 88 year old with dementia who is admitted
with shingles. Correct Answers A) A 72 year old female
weighing 82lbs with stress incontinence and dementia.
10. On a full body admission assessment, you note the patient
has a stage 3 pressure ulcer. How would you document the
appearance of the wound?
A. Area is red and does not blanch.
B. Full-thickness skin loss to dermis and subcutaneous tissues.
C. Partial thickness of dermis with shallow open ulcer.
D. Full thickness with bone and tendon visible. Correct
Answers B. Full-thickness skin loss to dermis and subcutaneous
tissues.
,10. The goal of nursing care of the client with an indwelling
catheter and continuous drainage is largely directed at
preventing infection of the urinary tract and encouraging urinary
flow through the drainage system. Which of the following
interventions encouraged by nurses working with these clients
would not be appropriate in meeting this goal?
A) Having the client drink up to 2000 mL per day
B) Encouraging the client to eat foods that increase the acid in
the urine
C) Routine hygienic care
D) Changing indwelling catheters every 72 hours. Correct
Answers D) Changing indwelling catheters every 72 hours.
Rationale: Retention catheters are removed after their purpose is
achieved; routine changing of the catheter or drainage system is
not recommended. Large amounts of fluid ensure a large urine
output, which keeps the bladder flushed out and decreases the
likelihood of urinary stasis and subsequent infection. Eating
foods that increase the acid in urine helps to reduce the risk of
urinary tract infections and stone formation. Hygiene care
related to catheters is set by hospital policy.
10. The goal of nursing care of the client with an indwelling
catheter and continuous drainage is largely directed at
preventing infection of the urinary tract and encouraging urinary
flow through the drainage system. Which of the following
, interventions encouraged by nurses working with these clients
would not be appropriate in meeting this goal?
A) Having the client drink up to 2000 mL per day
B) Encouraging the client to eat foods that increase the acid in
the urine
C) Routine hygienic care
D) Changing indwelling catheters every 72 hours. Correct
Answers D) Changing indwelling catheters every 72 hours.
Rationale: Retention catheters are removed after their purpose is
achieved; routine changing of the catheter or drainage system is
not recommended. Large amounts of fluid ensure a large urine
output, which keeps the bladder flushed out and decreases the
likelihood of urinary stasis and subsequent infection. Eating
foods that increase the acid in urine helps to reduce the risk of
urinary tract infections and stone formation. Hygiene care
related to catheters is set by hospital policy.
2. A home health nurse knows that a 70-year-old male client
who is convalescing at home following a hip replacement is at
risk for developing pressure ulcers. Which physical
characteristic of aging puts the client at greatest risk?
A. 16% increase in overall body fat
B. Reduced melanin production
Solutions
1. You are assigned four patients on your nursing unit. Which
patient is at most risk for pressure ulcers?
A) A 72 year old female weighing 82lbs with stress incontinence
and dementia.
B) A 90 year old male with Congestive Heart Failure who has
3+ pitting edema in lower extremities.
C) A 6 month old with the flu.
D) An ambulatory 88 year old with dementia who is admitted
with shingles. Correct Answers A) A 72 year old female
weighing 82lbs with stress incontinence and dementia.
10. On a full body admission assessment, you note the patient
has a stage 3 pressure ulcer. How would you document the
appearance of the wound?
A. Area is red and does not blanch.
B. Full-thickness skin loss to dermis and subcutaneous tissues.
C. Partial thickness of dermis with shallow open ulcer.
D. Full thickness with bone and tendon visible. Correct
Answers B. Full-thickness skin loss to dermis and subcutaneous
tissues.
,10. The goal of nursing care of the client with an indwelling
catheter and continuous drainage is largely directed at
preventing infection of the urinary tract and encouraging urinary
flow through the drainage system. Which of the following
interventions encouraged by nurses working with these clients
would not be appropriate in meeting this goal?
A) Having the client drink up to 2000 mL per day
B) Encouraging the client to eat foods that increase the acid in
the urine
C) Routine hygienic care
D) Changing indwelling catheters every 72 hours. Correct
Answers D) Changing indwelling catheters every 72 hours.
Rationale: Retention catheters are removed after their purpose is
achieved; routine changing of the catheter or drainage system is
not recommended. Large amounts of fluid ensure a large urine
output, which keeps the bladder flushed out and decreases the
likelihood of urinary stasis and subsequent infection. Eating
foods that increase the acid in urine helps to reduce the risk of
urinary tract infections and stone formation. Hygiene care
related to catheters is set by hospital policy.
10. The goal of nursing care of the client with an indwelling
catheter and continuous drainage is largely directed at
preventing infection of the urinary tract and encouraging urinary
flow through the drainage system. Which of the following
, interventions encouraged by nurses working with these clients
would not be appropriate in meeting this goal?
A) Having the client drink up to 2000 mL per day
B) Encouraging the client to eat foods that increase the acid in
the urine
C) Routine hygienic care
D) Changing indwelling catheters every 72 hours. Correct
Answers D) Changing indwelling catheters every 72 hours.
Rationale: Retention catheters are removed after their purpose is
achieved; routine changing of the catheter or drainage system is
not recommended. Large amounts of fluid ensure a large urine
output, which keeps the bladder flushed out and decreases the
likelihood of urinary stasis and subsequent infection. Eating
foods that increase the acid in urine helps to reduce the risk of
urinary tract infections and stone formation. Hygiene care
related to catheters is set by hospital policy.
2. A home health nurse knows that a 70-year-old male client
who is convalescing at home following a hip replacement is at
risk for developing pressure ulcers. Which physical
characteristic of aging puts the client at greatest risk?
A. 16% increase in overall body fat
B. Reduced melanin production
