Test 3

Question 1

A patient that has his entire large intestinge and rectum removed will have what type of ostomy:

A. cecostomy
B. loop colostomy
C. ileostomy
D. descending colostomy

Answer 1

D. Descending colostomy

Question 2

A nurse is replacing the ostomy appliance for a patient whose newly created colostomy is functioning. After removing the pouch, which of the following should the nurse do first?

A. measure the stoma
B. cover the stoma with gauze
C. remove the backing on the skin barrier
D. cleanse the stoma and the peristomal skin.

Answer 2

D. cleanse the stoma and the peristomal skin

Question 3

A patient who has bladder cancer tells the nurse that she prefers a urinary diversion that will allow her to have some control over urinary elimination. Which option will allow that:

A. kock’s pouch
B. ileal conduit
C. cutaneous ureterostomy
D. nephrostomy

Answer 3

A. kock’s pouch

Question 4

To prevent excoriation and breakdown of the peristomal skin, the nurse should instruct the patient to :

A. apply hydrocortisone cream to the skin when changing the appliance.
B..empty the pouch when it is no more than half full.
C. wash the peristomal skin frequently with deodorizing soap and water.
D. Choose a time shortly after a meal for replacing the pouch.

Answer 4

B. empty the pouch when it is no more than half full.

Question 5

A nurse is administering an enema medicated with Kayexalate to an older adult patient who has hyperkalemia. The nurse should insert the tip of the rectal tube

A. 1 to 1.5 in
B. 2 to 3 in
C. 3 to 4 in
D. 4 to 5 in

Answer 5

C. 3 to 4 in.

Question 6

The nurse explains that the patient should try to retain the instilled oil enema for

A. As long as it takes to complete the procedure.
B. about 10 to 15 min.
C. until the next time he feels the urge to defecate
D. at least 30 min, but preferably as long as he can.

Answer 6

D. at least 30 min, but preferably as long as he can.

Question 7

A nurse who is administering a return-flow enema to a patient should instill 100 mL of enema fluid and then

A. instruct the patient to retain the fluid
B. lower the container to allow the solution to flow back out.
C. help the patient to the toilet or bedside commode.
D. wait 5 min and instill another 100 mL of fluid

Answer 7

B. lower the container to allow the solution to flow back out.

Question 8

A nurse is preparing an older adult patient for an enema. The nurse should assist the patient to which of the following positions?

A. prone
B. dorsal recumbent
C. right lateral with both knees at chest
D. Left lateral with the right leg flexed.

Answer 8

D. Left lateral with the right leg flexed.

Question 9

A patient who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. The nurse should anticipate receiving an order from the provider for which of the following types of enemas?

A. cleansing
B. return-flow
C. medicated
D. oil-retention

Answer 9

B. return-flow

Question 10

While a nurse is administering a cleansing enema, the patient reports abdominal cramping. Which of the following is the appropriate intervention?

A. measure the patient’s vital signs
B. notify the primary care provider
C. lower the enema fluid container
D. stop the enema instillation

Answer 10

C. lower the enema fluid container

Question 11

Because a client is scheduled for a colonoscopy, the nurse will instruct the client to perform which of the following?

A. Oil retention enema
B. Return flow enema
C. High, large volume enema
D. Low, small volume enema

Answer 11

D. Low, small volume enema

Rationale: Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option 1). Return flow enemas help expel flatus (option 2). Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used (option 3).

Question 12

Which of the following is the most appropriate nursing goal for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection?

A. The client will wear a medic-alert bracelet for antibiotic allergy.
B. The client will return to his or her previous fecal elimination pattern.
C. The client verbalizes the need to take an antidiarrheal medication prn.
D. The client will increase intake of insoluble fiber such as grains, rice, and cereals.

Answer 12

B. The client will return to his or her previous fecal elimination pattern

Question 13

The nurse assesses a client’s abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling “bloated.” The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema?

A. Soapsuds enema
B. Retention enema
C. Return flow enema
D. Oil retention enema

Answer 13

C. Return flow enema

Rationale: This provides relief of postoperative flatus, stimulating bowel motility. Options 1, 2, and 4 manage constipation and do not provide flatus relief.

Question 14

A nurse in a clinic is reinforcing teaching to a client how to do fecal occult blood testing. Which of the following statements indicates a need for clarification:

A. I will continue my low dose aspirin therapy regimen
B. I will refrain from eating raw fruits and vegetables
C. I will avoid steak and other red meats.
D. I will continue taking my Coumadin as prescribed.

Answer 14

D. I will continue taking my Coumadin as prescribed.

Question 15

A nurse is reinforcing discharge teaching with a client about how to care for a newly created ileal conduit. The nurse will instruct the client to empty the appliance:

A. daily at bedtime when connecting to a night drainage system.
B. every 2 hr to prevent leakage
C. twice a day to prevent infection
D. when full to use fewer new appliances

Answer 15

B. every 2 hr to prevent leakage

Question 16

A nurse in a clinic is preparing information on low fiber diet restrictions for a client who has an ulcerative colitis. Which of the following foods should be eliminated in the client’s diet?

A. cooked cabbage
B. dried apricots
C. ripe bananas
D. ice cream

Answer 16

B. dried apricots

Question 17

A nurse is reinforcing teaching for a client who is post-operative from having an ileostomy established. Which of the following should the nurse include in the teaching?

A. empty the pouch immediately after meals
B. change the entire appliance once a day
C. limit fluid intake
D. avoid medications in capsule or enteric form

Answer 17

D. avoid medications in capsule or enteric form

Question 18

Which of the following statements indicates an understanding of collecting a midstream urine sample:

A. I’ll urinate a little then stop
B. I’ll use the cleansing wipe from front to back
C. I’ll dry the outside of the container with a paper towel
D. I’ll use each cleansing wipe twice

Answer 18

B. I’ll use the cleansing wipe from front to back

Question 19

The stool guaiac testing is for which of the following:

A. bacteria
B. parasites
C. blood
D. fat

Answer 19

C. blood

Question 20

Which of the following should the nurse instruct a client to avoid for at least three days before a fecal occult blood test:

A. whole grain cereals
B. Milk of Magnesia
C. orange juice
D. Tylenol

Answer 20

C. orange juice

Question 21

A nurse is monitoring a child for acute signs of lead poisioning. Which of the following should the nurse expect the client to manifest:

A. increased urinary output
B. anorexia
C. diarrhea
D. jaundice

Answer 21

B. anorexia

Question 22

Which of the following is an appropriate action by the nurse when administering a cleansing enema:

A. keep the container of solution at a level to maintain client comfort.
B. hold the container of solution 12 inches above the anus.
C. hold the container of solution level with the upper hip.
D. slowly lower the container of solution 24 inches below the anus.

Answer 22

B. hold the container of solution 12 inches above the anus.

Question 23

Which of the following indicates a complication of a restraint:

A. the client has a capillary refill of less than two seconds
B. the client has full range of motion in her wrist
C. the client is attempting to remove the restraint
D. the client’s hand is cool and pale

Answer 23

D. the client’s hand is cool and pale

Question 24

The first step by the nurse when inserting a indwelling urinary catheter is:

A. use minimal lubrication to minimize friction at the meatus
B. cleanse the urinary meatus before catheterization
C. cleanse the perineal area using back to front motion.
D. irrigate the cteter prior to insertion to assess patency of the catheter.

Answer 24

B. cleanse the urinary meatus before catheterization

Question 25

The nurse understands that which of the following rationales is most important for the removal of dentures preoperatively:

A. the dentures can get lost in surgery
B. the dentures can be broken during anesthesia
C. the dentures can interfere with respirations
D. the dentures can interfere with the placement of the endotracheal tube

Answer 25

C. the dentures can interfere with respirations

Question 26

A nurse is caring for an older adult client who reports constipation. Which of the following is an appropriate nursing recommendation:

A. bear down hard when defecating
B. drink 600 mL of water daily
C. eat raw vegetables
D. limit activity

Answer 26

C. eat raw vegetables

Question 27

A nurse is planning care for a child that has severe diarrhea. Which of the following is the priority nursing action?

A. introduce a regular diet
B. rehydrate
C. maintain fluid therapy
D. assess fluid balance

Answer 27

D. assess fluid balance

Question 28

Which of the following conditions should the nurse report to the provider:

A. stoma oozing red drainage
B. shiny moist stoma
C. purplish colored stoma
D. rosebud appearing stoma orifice

Answer 28

C. purplish colored stoma

Question 29

The stage when the family begins to loosen its influence and let go of its hold on its members is termed family:

A. childbearing
B. launching
C. aging
D. beginning

Answer 29

B. launching

Question 30

The nurse who is ethnocentric delivers nursing care that demonstrates:  
A.  cultural sensitivity
B.  cultural pluralism
C.  cultural relativism
D.  cultural superiority

Answer 30

D. cultural superiority

Question 31

Pregnancy and childbirth are viewed as natural and are often attended by several close family members in this culture:

A. Hispanic American
B. Asian American
C. Native American
D. Arab American

Answer 31

C. Native American

Question 32

The nurse understands that grooming and hygiene in mentally ill clients may likely be:

A. heightened
B. diminished
C. stressful
D. at an optimal level

Answer 32

B. diminished

Question 33

The nursing assistant is performing foot case for an elderly client. The CNA should be interrupted if he or she:

A. cuts the toenails straight across
B. scrubs the toenails with a nail brush
C. submerges both feet in warm water
D. cuts the corner of the toenail to round it off.

Answer 33

D. cuts the corner of the toenail to round it off.

Question 34

An expected outcome of hot application is:

A. improved sensation
B. decreased blood flow
C. erythema
D. decreased swelling

Answer 34

C. erythema

Question 35

The nurse should be concerned about which of the following:

A. a client who does not have the urge to void at night
B. a client on an anticoagulant with pink urine
C. a client who states that he voids more after drinking coffee
D. a two year old with occasional bedwetting

Answer 35

B. a client on an anticoagulant with pink urine

Question 36

Specific gravity of urine measures:

A. osmotic pressure of the urine
B. concentration of urine compared to water
C. filtration pressure
D. acidity of urine

Answer 36

B. concentration of urine compared to water

Question 37

Common signs of fecal impaction includes:

A. increased bowel sounds
B. frequent loose stools
C. increased flatulence
D. hemorrhoids

Answer 37

B. frequent loose stools

Question 38

The regular use of mineral oil as a laxative may lead to:

A. decreased absorption of fat soluable vitamins.
B. increased absorption of insoluble waste
C. fecal impaction
D. decreased peristalsis

Answer 38

A. decreased absorption of fat soluable vitamins.

Question 39

The nurse recognizes that normal aging changes may produce decreased bladder contractility. The nurse can expect that this change may predispose the older client to:

A. diminished urinary concentration
B. diminished awareness to void
C. increased urinary frequency
D. urinary retention and stasis

Answer 39

D. urinary retention and stasis