Week 6

Question 1

When preparing to apply a condom catheter, the nurse would do what first?

Answer 1

Close the door and draw the bedside curtain.

Question 2

Which instruction might the nurse give to an unregulated care provider (UCP) about applying a condom catheter on a patient?

Answer 2

Read the manufacturer’s instructions for applying the adhesive to secure the condom.

Question 3

Which instruction would the nurse give to an unregulated care provider (UCP) to ensure the patient’s comfort when a condom catheter is applied?

Answer 3

Use a hair guard before applying the condom catheter. Correct

Question 4

Why would the nurse ensure that a patient’s condom catheter is not twisted?

Answer 4

To prevent the catheter from coming of

Question 5

What would the nurse do for a patient who is complaining of penile pain 15 minutes after having a condom catheter applied?

Answer 5

Remove the catheter.

Question 6

What is included in the preparation for an assessment of the patient with female genitalia?

Answer 6

Explaining the exam thoroughly if it is the patient’s first exam and having the patient empty the bladder

Question 7

When should gloves be changed or discarded?

Answer 7

After touching the genital skin
After completing the internal vaginal exam
After completing the rectal exam
All of these choices

Question 8

Which description is consistent with normal vaginal secretions?

Answer 8

Clear or cloudy, and odorless or with a slight odour

Question 9

What is a Pap smear?

Answer 9

A screening test for cervical cancer

Question 10

Screening for endometrial cancer consists of reinforcing the need to report:

Answer 10

Unexpected vaginal bleeding or spotting

Question 11

Which of the following should be included in the examination of a patient with male genitalia?

Answer 11

Teaching the patient how to do self-exams Incorrect
Palpating for abnormalities
Retracting and replacing the foreskin in an uncircumcised patient
All of these choices

Question 12

Nocturia, urine dribbles, difficulty voiding, and a small urine stream are common symptoms of which of the following conditions?

Answer 12

Benign prostatic hypertrophy

Question 13

In which of the following age groups is screening for early detection of colorectal cancer strongly recommend?

Answer 13

Patients between 60 and 74 years of age

Question 14

Which of the following patients are considered at increased risk for colon cancer?

Answer 14

Patients with a history of chronic inflammatory bowel disease and a family history of adenomatous polyposis

Question 15

Which possible signs and symptoms of testicular cancer should be reported to a physician?

Answer 15

A lump, tenderness, or swelling in the scrotum or testicles Incorrect
Unexplained weight loss
Breast development
All of these choices

Question 16

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter?

Answer 16

Use the smallest-size catheter possible.

Question 17

Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?

Answer 17

Assessing the patient for allergies related to latex, antiseptic, tape, and/or lubricant

Question 18

Which statement best illustrates the nurse’s understanding of the role of the unregulated care provider (UCP) when inserting an indwelling urinary catheter in a patient with female genitalia?

Answer 18

“Please direct the light to better illuminate the patient’s perineal area.”

Question 19

The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next?

Answer 19

Remove soiled gloves, and perform hand hygiene.

Question 20

A patient with female genitalia placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that they “don’t feel comfortable in this position” and that their “back really hurts.” What is the nurse’s best response?

Answer 20

Reposition the patient in a side-lying position, with their upper leg flexed at the knee and hip.

Question 21

What is the best reason for the nurse to instruct a patient with male genitalia to take slow, deep breaths during insertion of an indwelling urinary catheter?

Answer 21

To promote relaxation

Question 22

When preparing to insert an indwelling urinary catheter in a patient with male genitalia, it is important for the nurse to do what?

Answer 22

Lubricate the first 12.5 to 17.5 cm (5 to 7 inches) of the catheter.

Question 23

Which observation indicates that instruction given to the unregulated care provider (UCP) in caring for a patient with an indwelling urinary catheter has been effective?

Answer 23

The excess catheter tubing has been coiled beside the patient’s inner thigh.

Question 24

While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a patient with male genitalia is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient’s risk for infection?

Answer 24

Replace all contaminated supplies, and begin the process again.

Question 25

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a patient with male genitalia with an indwelling urinary catheter?

Answer 25

Clean the urinary meatus daily.

Question 26

A patient is told the home care nurse will be measuring and recording intake and output (I&O) at home. What will the home care nurse do first?

Answer 26

Explain to the patient why I&O has been prescribed.

Question 27

What measurements will the nurse direct an unregulated care provider (UCP) to measure for a hospitalized patient for whom I&O measurement is prescribed?

Answer 27

Urine collection drainage

Question 28

Which statement reflects the nurse’s understanding of the importance of accurate urinary output measurement for a patient with acute renal failure?

Answer 28

“I will use a collection system with an hourly measurement device added.”

Question 29

A patient has consumed three 100-mL cups of ice chips and 4 ounces of ginger ale. What will an unregulated care provider (UCP) document as this patient’s oral intake?

Answer 29

270 mL

Question 30

A patient is admitted to your unit for dehydration. Which of the following assessments would the nurse identify as a possible sign of fluid imbalance?

Answer 30

Reduced turgor of the skin

Question 31

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter?

Answer 31

Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

Question 32

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results?

Answer 32

Having someone take the specimen to the lab immediately

Question 32

Which statement might the nurse make to the unregulated care provider (UCP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter?

Answer 32

“Let me know if the urine contains blood or sediment or appears cloudy.”

Question 32

Which measure may be taken to minimize the staff’s risk for infection from a urine specimen?

Answer 32

Firmly securing the lid of the urine specimen container

Question 32

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected?

Answer 32

Clamping the catheter tubing for 15 minutes before collection

Question 33

While performing an intermittent straight urinary catheterization of a patient with female genitalia, the nurse inadvertently inserts the catheter into the patient’s vagina. Which action would the nurse take next?

Answer 33

Keep the catheter in place, and begin again with a new sterile catheter.

Question 34

While attempting to perform a straight catheterization for a patient with male genitalia, the nurse advances the catheter 5 to 7.5 cm (2 to 3 inches) into the meatus but observes no urine flow. Which action would the nurse take at this time?

Answer 34

Continue to advance the catheter until 17 to 22.5 cm (7 to 9 inches) of the catheter tube has been introduced into the urethra.

Question 35

The nurse instructs the unregulated care provider (UCP) regarding proper technique for intermittent straight catheterization of a patient with male genitalia. Which statement made by the UCP indicates that the instruction was effective?

Answer 35

“I’ll help keep their legs away from the sterile field.”

Question 36

Why does the nurse cleanse the perineum of a patient with female genitalia before inserting an intermittent urinary catheter?

Answer 36

To reduce the patient’s risk of urinary tract infection

Question 37

The nurse has completed an intermittent straight urinary catheterization of a patient with female genitalia. Which action would the nurse delegate to the unregulated care provider (UCP)?

Answer 37

Measure and empty the urine.

Question 38

What is the primary reason the nurse ensures that a patient’s indwelling urinary catheter drainage tubing is free of kinks?

Answer 38

Kinks are associated with the development of urinary tract infection (UTI).

Question 39

The nurse has delegated measurement of a patient’s vital signs and catheter care to an unregulated care provider (UCP). Which observation should the UCP report to the nurse immediately?

Answer 39

Redness noted on the external urethral meatus

Question 40

All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one?

Answer 40

Use of plain soap instead of an antiseptic cleanser for perineal hygiene

Question 41

While performing catheter care, the nurse moves their hand, allowing the patient’s labia to close around the catheter. Why would the nurse repeat this part of the care?

Answer 41

The labia have contaminated the area.

Question 42

What is the most effective way to prevent infection when providing catheter care for a patient?

Answer 42

Cleanse from the meatus outward.

Question 43

When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication?

Answer 43

Urinary tract infection (UTI)

Question 44

Which action would best minimize a patient’s risk for infection during removal of an indwelling urinary catheter?

Answer 44

The nurse or unregulated care provider (UCP) removing the catheter must employ clean technique.

Question 45

Which statement might the nurse make to the unregulated care provider (UCP) caring for a patient who has just had an indwelling urinary catheter removed?

Answer 45

“Tell me when and how much the patient first voids.”

Question 46

Which nursing action minimizes a patient’s risk for injury during removal of an indwelling urinary catheter?

Answer 46

Checking the documentation for the volume of fluid used to inflate the balloon

Question 47

Which is not an expected outcome on a first voiding after catheter removal?

Answer 47

Fever and back pain

Question 48

Testing with a urine reagent test strip shows that a patient’s urine is positive for protein, negative for glucose and blood, and has a pH of 8.2. What will the nurse do in response to these results?

Answer 48

Notify the health care provider of the results of the test.

Question 49

Which action is necessary for an accurate chemical reaction when testing urine with a reagent test strip?

Answer 49

Keep the test strip horizontal while timing the process.

Question 50

Which statement will the nurse make to an unregulated care provider (UCP) when delegating urine glucose testing with a reagent strip for a patient with type 2 diabetes?

Answer 50

“Be sure to get a double-voided specimen when you test the patient’s urine.”

Question 51

What is a double-voided urine specimen?

Answer 51

A second urine specimen taken within 40 minutes after the patient voids

Question 52

Which action is performed initially when using a reagent strip to test the urine of a patient with type 1 diabetes for glucose?

Answer 52

Verify the patient using two patient identifiers.

Question 53

What is the correct order for abdominal assessment?

Answer 53

Inspection, auscultation, percussion, palpation

Question 54

How often should normal bowel sounds be heard in each quadrant of the abdomen?

Answer 54

5–30 times per minute

Question 55

Which of the following is an important part of performing an abdominal assessment?

Answer 55

Explaining each step of the assessment to the patient

Question 56

What should you do if a patient is ticklish when you are palpating the abdomen?

Answer 56

Place your hand over the patient’s hand during palpation.

Question 57

Deep palpation of the abdomen:

Answer 57

May cause tenderness Should not detect masses Should never be done over a surgical incision All of these choices