Fundamentals of Nursing NCLEX Practice excess adipose tissue in skinfold areas can have an

Exam: Part 3 increased risk of skin injury such as friction, maceration,

skin tears and pressure ulcer development.
Option B: Skin folds and areas vulnerable to skin injury
1. The charge nurse asks the nursing assistive
should be cleaned and dried several times a day.
personnel (NAP) to give a bag bath to a patient with
Alcohol-based lotions and harsh soaps, as well as
end-stage chronic obstructive pulmonary disease. How
talcum powders, should be avoided in these areas. If
should the NAP proceed?
necessary, dry cloths to absorb moisture can be left in
A. Bathe the patient's entire body using 8 to 10 skin folds in between washing and drying of the skin
washcloths. folds.
Option D: Petrolatum barrier creams are used to
B. Assist the patient to a chair and provide bathing
minimize moisture caused by incontinence. Patient
supplies.
hydration should also be considered in the nutrition plan
C. Saturate a towel and blanket in a plastic bag, and
for the patients and the health of their skin.
then bathe the patient.
D. Assist the patient to the bathtub and provide a bath
chair.
3. A client exhibits all of the following during a physical
A towel bath is a modification of the bed bath in which assessment. Which of these is considered a primary
the NAP places a large towel and a bath blanket into a defense against infection?
plastic bag, saturates them with a commercially
prepared mixture of moisturizer, non rinse cleaning A. Fever
agent, and water; warms in them in a microwave, and B. Intact skin
then uses them to bathe the patient. A bag bath is a C. Inflammation
modification of the towel bath, in which the NAP uses 8 D. Lethargy
to 10 washcloths instead of a towel or blanket. Each part
of the patient’s body is bathed with a fresh cloth. Intact skin is considered a primary defense against
infection. Usually, the skin prevents invasion by
Option B: A bag bath is not given in a chair or in the microorganisms unless it is damaged (for example, by
tub. The bag bath is one alternative to the traditional bed an injury, insect bite, or burn). Mucous membranes,
bath used in some nursing homes. The bath is such as the lining of the mouth, nose, and eyelids, are
performed with a series of 10 washcloths and a no-rinse also effective barriers. Typically, mucous membranes
liquid cleanser. Close the door and windows to prevent are coated with secretions that fight microorganisms.
cold drafts and wash hands with warm water before For example, the mucous membranes of the eyes are
beginning. bathed in tears, which contain an enzyme called
Option C: Moisten the washcloths with water and put in lysozyme that attacks bacteria and helps protect the
a plastic bag with the cleanser. Warm the bag in the eyes from infection. Fever, the inflammatory response,
microwave for 60 to 90 seconds. Test the temperature of and phagocytosis (a process of killing pathogens) are
the clothes before touching a resident with them and be considered secondary defenses against infection.
careful when you open the bag, as steam can burn.
Option D: Take the bag to the resident’s bedside. When Option A: Body temperature increases as a protective
you are not cleaning a body part, keep it covered. Only response to infection and injury. An elevated body
expose as much of the resident’s body as necessary to temperature (fever) enhances the body’s defense
adequately clean him or her. Be especially sensitive to mechanisms, although it can cause discomfort. A part of
exposing genitals, buttocks, and breasts. Bathing can be the brain called the hypothalamus controls body
an extremely stressful experience for residents, so try to temperature. Fever results from an actual resetting of
make it as easy as possible. the hypothalamus’s thermostat. The body raises its
temperature to a higher level by moving (shunting) blood
from the skin surface to the interior of the body, thus
reducing heat loss.
2. For a morbidly obese patient, which intervention
Option C: Any injury, including an invasion by
should the nurse choose to counteract the pressure
microorganisms, causes inflammation in the affected
created by the skin folds?
area. Inflammation, a complex reaction, results from
many different conditions. During inflammation, the
A. Cover the mattress with a sheepskin.
blood supply increases, helping carry immune cells to
B. Keep the linens wrinkle free.
C. Separate the skin folds with towels. the affected area. Because of the increased blood flow,
an infected area near the surface of the body becomes
D. Apply petrolatum barrier creams.
red and warm. The walls of blood vessels become more
porous, allowing fluid and white blood cells to pass into
Separating the skin folds with towels relieves the
the affected tissue. The increase in fluid causes the
pressure of skin rubbing on skin. Skin folds, in particular,
inflamed tissue to swell. The white blood cells attack the
may be difficult for the patient to clean thoroughly; the
invading microorganisms and release substances that
abdominal folds and groins may be ignored, leading to
continue the process of inflammation.
an increased risk of skin breakdown in these areas.
Option D: Lethargy refers to a state of lacking energy.
Option A: Sheepskins are not recommended for use at People who are experiencing fatigue or tiredness can
also be said to be lethargic because of low energy. The
all. Skin folds present a challenge in the management of
same medical conditions that can lead to tiredness or
patients who are morbidly obese. The weight from
fatigue can also lead to lethargy.
 Option C: A client in protective isolation should not be
paired with a client who has an open wound, such as a
4. A client with a stage 2 pressure ulcer has methicillin- stage 3 pressure ulcer. Patient’s requiring protective
resistant Staphylococcus aureus (MRSA) cultured from isolation should be nursed in a single room. Where
the wound. Contact precautions are initiated. Which rule possible this room should have an ante-room, positive
must be observed to follow contact precautions? pressure ventilation and Hepa filtered air. The room
should have an en-suite and hand washing facilities and
A. A clean gown and gloves must be worn when in the doors(s) should be kept closed at all times.
contact with the client. Option D: A client in protective isolation should not be
B. Everyone who enters the room must wear a N-95 paired with a client who has a urinary tract infection.
respirator mask. Many infections acquired by immunocompromised
C. All linen and trash must be marked as contaminated patients are endogenous infections (An infection caused
and send to biohazard waste. by an infectious agent that is already present in the body
D. Place the client in a room with a client with an upper but has previously been inapparent or dormant),
respiratory infection. however, the transmission of infection from other
patients, staff, or the environment can be a risk and
A clean gown and gloves must be worn when any therefore extra precautions are required.
contact is anticipated with the client or with
contaminated items in the room. Visitors might also be
asked to wear a gown and gloves. Patients are asked to 6. A newly hired at Nurseslabs Medical Center is
stay in their hospital rooms as much as possible. They assigned to the OR Department. Which action
should not go to common areas, such as the gift shop or demonstrates a break in sterile technique?
cafeteria. They may go to other areas of the hospital for
treatments and tests. A. Remaining 1 foot away from non sterile areas.
B. Placing sterile items on the sterile field.
Option B: A respirator mask is required only with C. Avoiding the border of the sterile drape.
airborne precautions, not contact precautions. D. Reaching 1 foot over the sterile field.
Healthcare providers will put on gloves and wear a gown
over their clothing while taking care of patients with Reaching over the sterile field while wearing sterile garb
MRSA. breaks the sterile technique. While observing sterile
Option C: All linen must be double-bagged and clearly technique, healthcare workers should remain 1 foot
marked as contaminated. When leaving the room, away from non-sterile areas while wearing sterile garb,
healthcare providers and visitors remove their gown and place sterile items needed for the procedure on the
gloves and clean their hands. sterile drape, and avoid coming in contact with the 1-
Option D: The client should be placed in a private room inch border of the sterile drape. The principles of the
or in a room with a client with an active infection caused Sterile Technique are applied in various ways. If the
by the same organism and no other infections. principle itself is understood, the applications of it
Whenever possible, patients with MRSA will have a become obvious. A strict aseptic technique is needed at
single room or will share a room only with someone else all times in the Operating Room.
who also has MRSA.
Option A: Sterile persons avoid leaning over an
unsterile area; non-sterile persons avoid reaching over a
5. A client requires protective isolation. Which client can sterile field. Unsterile persons do not get closer than 12
be safely paired with this client in a client-care inches from a sterile field.
assignment? One: Option B: Persons who are sterile touch only sterile
articles; persons who are not sterile touch only unsterile
A. Admitted with unstable diabetes mellitus. articles. If in doubt about the sterility of anything
B. Who underwent surgical repair of a perforated bowel. consider it not sterile. If a non-sterile person brushes
C. With a stage 3 sacral pressure ulcer. close consider yourself contaminated.
D. Admitted with a urinary tract infection. Option C: Sterile persons keep contact with sterile
areas to a minimum. Do not lean on the sterile tables or
The client with unstable diabetes mellitus can safely be on the draped patient. Do not lean on the nurse’s mayo
paired in a client-care assignment because the client is tray.
free from infection. Protective Isolation aims to protect
an immunocompromised patient who is at high risk of
acquiring micro-organisms from either the environment 7. Nurse Berta is facilitating a monthly mothers’ class at
or from other patients, staff, or visitors. a small village. As a knowledgeable nurse, she must
know that a mother who breastfeeds her child passes on
Option B: Perforation of the bowel exposes the client to which antibody through breast milk?
infection requiring antibiotic therapy during the
postoperative period. Therefore, this client should not be A. IgA
paired with a client in protective isolation. Patients B. IgE
should remain in isolation whilst they remain C. IgG
symptomatic; a risk assessment should be undertaken D. IgM
to ascertain if and when isolation precautions can be
relaxed. Antibodies, which are also called immunoglobulins, take
five basic forms, indicated as IgG, IgA, IgM, IgD and
IgE. All have been detected in human milk, but by far the microorganisms, except perhaps briefly when an
most abundant type is IgA, particularly the form known antiseptic agent is used for cleansing. Handwashing with
as secretory IgA, which is found in great amounts soap could protect about 1 out of every 3 young children
throughout the gut and respiratory system of adults. The who get sick with diarrhea and almost 1 out of 5 young
secretory IgA molecules passed to the suckling child are children with respiratory infections like pneumonia.
helpful in ways that go beyond their ability to bind to
microorganisms and keep them away from the body’s
tissues. 9. Which of the following incidents requires the nurse to
complete an occurrence report?
Option B: IgE is a monomer. It has a molecular weight
of 188 Kd and a serum concentration of 0.00005 mg/mL. A. Medication given 30 minutes after scheduled dose
It protects against parasites and also binds to high- time.
affinity receptors on mast cells and basophils causing B. Patient's dentures lost after transfer.
allergic reactions. IgE is regarded as the most important C. Worn electrical cord discovered on an IV infusion
host defense against different parasitic infections which pump.
include Strongyloides stercoralis, Trichinella spiralis, D. Prescription without the route of administration.
Ascaris lumbricoides, and the hookworms Necator
americanus and Ancylostoma duodenal. You would need to complete an occurrence report if you
Option C: IgG2 forms an important host defense suspect your patient’s personal items to be lost or
against bacteria that are encapsulated. IgG is the only stolen. An incident report also provides vital information
immunoglobulin that crosses the placentae as its Fc the facility needs to decide whether restitution should be
portion binds to the receptors present on the surface of made—if personal belongings were lost or damaged, for
the placenta, protecting the neonate from infectious example. Without proper documentation of the incident,
diseases. IgG is thus the most abundant antibody there’s no way to make these important decisions
present in newborns. effectively.
Option D: IgM has a molecular weight of 970 Kd and an
average serum concentration of 1.5 mg/ml. It is mainly Option A: A medication can be administered within a
produced in the primary immune response to infectious half-hour of the administration time without an error in
agents or antigens. It is a pentamer and activates the administration; therefore, an occurrence report is not
classical pathway of the complement system. IgM is necessary. An incident report invariably makes its way
regarded as a potent agglutinin (e.g., anti-A and anti-B to risk managers and other administrators, who review it
isoagglutinin present in type B and type A blood rapidly and act quickly to change any policy or
respectively) and a monomer of IgM is used as a B cell procedure that appears to be a key contributing factor to
receptor (BCR). the incident.
Option C: The worn electrical cord should be taken out
of use and reported to the biomedical department. An
8. The clinical instructor asks her students the rationale incident report should be filed whenever an unexpected
for handwashing. The students are correct if they event occurs. The rule of thumb is that any time a
answered that handwashing is expected to remove: patient makes a complaint, a medication error occurs, a
medical device malfunctions, or anyone—patient, staff
A. Transient flora from the skin member, or visitor—is injured or involved in a situation
B. Resident flora from the skin with the potential for injury, an incident report is
C. All microorganisms from the skin required.
D. Media for bacterial growth Option D: The nurse should seek clarification if the
provider’s order is missing information; an occurrence
There are two types of normal flora: transient and report is not necessary. The medical record is patient-
resident. Transient flora are normal flora that a person focused, and facts pertinent to an unexpected incident
picks up by coming in contact with objects or another will likely be left out. So if a claim were filed and the
person (e.g., when you touch a soiled dressing). You case proceeded to court, which sometimes occurs years
can remove these with hand washing. Hand washing after the event, you or anyone else involved might be
can prevent about 30% of diarrhea-related illnesses and hard-pressed to recreate the scene—especially if you
about 20% of respiratory infections (e.g., colds). consider it to be “minor” at the time. You may not be
Antibiotics often are prescribed unnecessarily for these able to rely on memory alone, but you can count on the
health issues incident report to refresh your memory.

Option B: Resident flora live deep in skin layers where

they live and multiply harmlessly. They are permanent 10. The nurse is orienting a new nurse to the unit and
inhabitants of the skin and cannot usually be removed reviews source-oriented charting. Which statement by
with routine hand washing. the nurse best describes source-oriented charting?
Option C: Removing all microorganisms from the skin Source-oriented charting:
(sterilization) is not possible without damaging the skin
tissues. To live and thrive in humans, microbes must be A. Separates the health record according to
able to use the body’s precise balance of food, moisture, discipline.
nutrients, electrolytes, pH, temperature, and light. B. Organizes documentation around the patient's
Option D: Food, water, and soil that provide these problems.
conditions may serve as nonliving reservoirs. Hand C. Highlights the patient's concerns, problems, and
washing does little to make the skin uninhabitable for strengths.
D. Is designed to streamline documentation.

In source-oriented charting, each discipline documents 12. The nurse is working on a unit that uses nursing
findings in a separately labeled section of the chart. assessment flow sheets. Which statement best
Source-oriented (SO) charting is a narrative recording describes this form of charting? Nursing assessment
by each member (source) of the health care team charts flow sheets:
on separate records. SO charting is time-consuming and
can lead to fragmented care. Effective documentation A. Are comprehensive charting forms that integrate
requires the use of common vocabulary; legibility and assessments and nursing actions.
neatness; the use of only authorized abbreviations and B. Contain only graphic information, such as I&O, vital
symbols; factual and time-sequenced organization; and signs, and medication administration.
accuracy, including any errors that occurred. All C. Are used to record routine aspects of care; they do
documents related to client care are confidential and not contain assessment data.
clients must sign a release to have their information D. Contain vital data collected upon admission, which
released, specifying what type of information may be can be compared with newly collected data.
released and to whom it may be released.
Nursing assessment flow sheets are organized by body
Option B: Problem-oriented charting organizes notes systems. The nurse checks the box corresponding to the
around the patient’s problems. POMR is a structured, current assessment findings. Nursing actions, such as
logical format of narrative charting, using “SOAP,” where wound care, treatments, or IV fluid administration, are
S means “subjective data,” O means “objective data,” A also included. A flow sheet is simply a one- or two-page
means assessment data, and P means “plan.” Some form that gathers all the important data regarding a
institutions add, intervention, E, evaluation, and R, patient’s condition. The flow sheet is housed in the
revision, to the SOAP format. POMR is sometimes patient’s chart and serves as a reminder of care and a
altered to become a problem-oriented record (POR). record of whether care expectations have been met.
The critical components of POMR/POR are the
database; the problem list; the initial plan; and the Option B: Graphic information, such as vital signs, I&O,
progress notes, based on the SOAP, SOAPIE, or and routine care, may be found on the graphic record.
SOAPIER format. This where records of serial measurements and
Option C: Focus charting highlights the patient’s observations, nursing interventions, and nursing care
concerns, problems, and strengths. Focus Charting of F- plans are recorded.
DAR is intended to make the client and client concerns Option C: Nursing documentation covers a wide variety
and strengths the focus of care. It is a method of of issues, topics, and systems. Researchers,
organizing health information in an individual’s record. practitioners, and hospital administrators view
Focus Charting is a systematic approach to recordkeeping as an important element leading to
documentation. continuity of care, safety, quality care, and compliance.
Option D: Charting by exception is a unique charting Option D: The admission form contains baseline
system designed to streamline documentation. Charting information. In health care organizations, the EHR, oral
by exception (CBE) is a shorthand method of reports, handoffs, conferences, and health information
documenting normal findings, based on clearly defined technologies (HIT) are intended to facilitate information
normals, standards of practice, and predetermined flow. In particular, the JCAHO specifically
criteria for assessments and interventions. Significant conceptualizes the care planning process as the
findings or exceptions to the predefined norms are structuring framework for coordinating communication
documented in detail. that will result in safe and effective care.

11. When the nurse completes the patient’s admission 13. At the end of the shift, the nurse realizes that she
nursing database, the patient reports that he does not forgot to document a dressing change that she
have any allergies. Which acceptable medical performed for a patient. Which action should the nurse
abbreviation can the nurse use to document this finding? take?

A. NA A. Complete an occurrence report before leaving.

B. NDA B. Do nothing; the next nurse will document it was
C. NKA done.
D. NPO C. Write the note of the dressing change into an earlier
note.
The nurse can use the medical abbreviation NKA, which D. Make a late entry as an addition to the narrative
means no known allergies, to document this finding. notes.
NKA is the abbreviation for “no known allergies,”
meaning no known allergies of any sort. By contrast, If the nurse fails to make an important entry while
NKDA stands exclusively for “no known drug allergies.” charting, she should make a late entry as an addition to
the narrative notes. The nurse can only document care
Option A: NA is an abbreviation for not applicable. directly performed or observed. Therefore, the nurse on
Option B: NDA is an abbreviation for no known drug the incoming shift would not record the wound change
allergies. as performed. A primary purpose of documentation and
Option D: NPO is an abbreviation that means nothing recordkeeping systems is to facilitate information flow
by mouth. that supports the continuity, quality, and safety of care.
 Option B: Integrated plans of care (IPOC) are a
Option A: An occurrence report is not necessary in this combined charting and care plan format. It is care that is
case. The issue of completeness is important; Croke planned with people who work together to understand
cites failure to document as one of the six top reasons the service user and their carer(s), puts them in control,
that nurses face malpractice suits. In terms of overall and coordinates and delivers services to achieve the
completeness, Stokke and Kalfoss found many gaps in best outcomes
nursing documentation in Norway. Care plans, goals, Option D: A medication administration record (MAR) is
diagnoses, planned interventions, and projected used to document medications administered and their
outcomes were absent between 18 percent and 45 usage. A Medication Administration Record (MAR, or
percent of the time. eMAR for electronic versions), commonly referred to as
Option B: If documentation is omitted, there is no legal a drug chart, is the report that serves as a legal record
verification that the procedure was performed. of the drugs administered to a patient at a facility by a
Completeness of a record may have an impact on the healthcare professional. The MAR is a part of a patient’s
quality of care, but only if it reflects completeness of the permanent record on their medical chart.
right content. Echoed again here is that document focus,
rather than the patient-centric nature of the medical
record, does little to support shared understanding by 15. In the United States, the first programs for training
clinicians of care and the communication needed to nurses were affiliated with:
ensure the continuity, quality, and safety of care.
Option C: It is illegal to add to a chart entry that was A. The military
previously documented. The typical content and format B. General hospitals
of documentation—and its lack of accessibility—have C. Civil service
also resulted in document-centric rather than patient- D. Religious orders
centric records.
When the Civil War broke out, the Army used nurses
who had already been trained in religious orders.
14. Patient Z asks Nurse Toni why an electronic health Nursing started with religious orders. The Hindu faith
record (EHR) system is being used. Which response by was the first to write about nursing. In the United States,
the nurse indicates an understanding of the rationale for all training for nurses was affiliated with religious orders
an EHR system? until after the Civil War.

A. It includes organizational reports of unusual Option A: Although the Army did provide some training,
occurrences that are not part of the client's record. it occurred later than in the religious orders. Most people
B. This type of system consists of combined think of the nursing profession as beginning with the
documentation and daily care plans. work of Florence Nightingale, an upper class British
C. It improves interdisciplinary collaboration that woman who captured the public imagination when she
improves efficiency in procedures. led a group of female nurses to the Crimea in October of
D. This type of system tracks medication administration 1854 to deliver nursing service to British soldiers.
and usage over 24 hours. Option B: Although nurses were trained in hospitals, the
training and the hospitals were affiliated with religious
The EHR has several benefits for users, including orders. Upon her return to England, Nightingale
improving interdisciplinary collaboration and making successfully established nurse education programs in a
procedures more accurate and efficient. An Electronic number of British hospitals. These schools were
Health Record (EHR) is an electronic version of a organized around a specific set of ideas about how
patient’s medical history, that is maintained by the nurses should be educated, developed by Nightingale
provider over time, and may include all of the key often referred to as the “Nightingale Principles.”
administrative clinical data relevant to that persons care Option C: Civil service was not mentioned in Chapter 1
under a particular provider, including demographics, and was not a factor in the early 1800s. While
progress notes, problems, medications, vital signs, past Nightingale’s work was groundbreaking in that she
medical history, immunizations, laboratory data, and confirmed that a corps of educated women, informed
radiology reports The EHR automates access to about health and the ways to promote it, could improve
information and has the potential to streamline the the care of patients based on a set of particular
clinician’s workflow. The EHR also has the ability to principles, she was not the first to put these principles
support other care-related activities directly or indirectly into action.
through various interfaces, including evidence-based
decision support, quality management, and outcomes
reporting. 16. Which of the following is/are an example(s) of a
health restoration activity? Select all that apply.
Option A: An occurrence report is an organizational
record of an unusual occurrence or accident that is not a A. Administering an antibiotic every day.
part of the client’s record. The purpose of the incident B. Teaching the importance of handwashing.
report is to document the exact details of the occurrence C. Assessing a client's surgical incision.
while they are fresh in the minds of those who witnessed D. Advising a woman to get an annual mammogram
the event. This information may be useful in the future after age 50 years.
when dealing with liability issues stemming from the E. Attending rehabilitation of a fractured arm.
incident.
Health restoration activities help an ill client return to is to expand knowledge about human experiences
health. This would include taking an antibiotic every day through creative conceptualization and research. This
and assessing a client’s surgical incision. Hand washing knowledge is the scientific guide to living the art of
and mammograms both involve healthy people who are nursing. The discipline-specific knowledge is given birth
trying to prevent illness. and fostered in academic settings where research and
education move the knowledge to new realms of
Option A: Rehabilitation or restoration is defined as “a understanding.
set of interventions designed to optimize functioning and Option B: Having professional organizations is not
reduce disability in individuals with health conditions in included in accepted characteristics of either a
interaction with their environment”. profession or a discipline. The goal of the profession is
Option B: Disease prevention, understood as specific, to provide service to humankind through living the art of
population-based, and individual-based interventions for science. Members of the nursing profession are
primary and secondary (early detection) prevention, responsible for regulation of standards of practice and
aiming to minimize the burden of diseases and education based on disciplinary knowledge that reflects
associated risk factors. safe health service to society in all settings.
Option C: Rehabilitation helps a child, adult, or older Option D: Having a scope of practice is not included in
person to be as independent as possible in everyday accepted characteristics of either a profession or a
activities and enables participation in education, work, discipline. The discipline of nursing encompasses the
recreation, and meaningful life roles such as taking care knowledge in the extant frameworks and theories that
of a family. It does so by addressing underlying are embedded in the totality and simultaneity paradigms
conditions (such as pain) and improving the way an (Parse, 1987). These theories and frameworks explicate
individual function in everyday life, supporting them to the nature of nursing’s major phenomenon of concern,
overcome difficulties with thinking, seeing, hearing, the human-universe-health process.
communicating, eating, or moving around.
Option D: Secondary prevention deals with early
detection when this improves the chances for positive 18. The charge nurse on the medical-surgical floor
health outcomes (this comprises activities such as assigns vital signs to the nursing assistive personnel
evidence-based screening programs for early detection (NAP) and medication administration to the licensed
of diseases or for prevention of congenital vocational nurse (LVN). Which nursing model of care is
malformations; and preventive drug therapies of proven this floor following?
effectiveness when administered at an early stage of the
disease). A. Team nursing
Option E: Rehabilitation is highly person-centered, B. Case method nursing
meaning that the interventions and approach selected C. Functional nursing
for each individual depends on their goals and D. Primary nursing
preferences. Rehabilitation can be provided in many
different settings, from inpatient or outpatient hospital This medical-surgical floor is following the functional
settings to private clinics, or community settings such as nursing model of care, in which care is partitioned and
an individual’s home. assigned to a staff member with the appropriate skills.
For example, the NAP is assigned vital signs, and the
LVN is assigned medication administration. Functional
17. Which of the following aspects of nursing is essential nursing is task-oriented in scope. Instead of one nurse
to defining it as both a profession and a discipline? performing many functions, several nurses are given
one or two assignments. For example, there is a
A. Established standards of care medicine nurse whose sole responsibility is
B. Professional organizations administering medications.
C. Practice supported by scientific research
D. Activities determined by a scope of practice Option A: With team nursing, an RN or LVN is paired
with a NAP. The pair is then assigned to render care for
A profession must have knowledge that is based on a group of patients. Team nursing is a system that
technical and scientific knowledge. The theoretical distributes the care of a patient amongst a team that is
knowledge of a discipline must be based on research, all working together to provide for this person. This team
so both are scientifically based. The profession of consists of up to 4 to 6 members that has a team leader
nursing consists of persons educated in the discipline who gives jobs and instructions to the group.
according to nationally regulated, defined, and Option B: In case method nursing, one nurse cares for
monitored standards. The standards and regulations are one patient during her entire shift. Private duty nursing is
to preserve healthcare safety for members of society. an example of this care model. The case method is a
Although the discipline and the profession of nursing participatory, discussion-based way of learning where
have different goals, the raison d’être of nursing is the students gain skills in critical thinking, communication,
enhancement of quality of life for humankind. The and group dynamics. It is a type of problem-based
discipline provides the science lived in the art of learning.
practice. Option D: When the primary nursing model is utilized,
one nurse manages care for a group of patients 24
Option A: The American Nurses Association (ANA) has hours a day, even though others provide care during
developed standards of care, but they are unrelated to part of the day. A method of providing nursing services
defining nursing as a profession or discipline. Nursing is to inpatients whereby one nurse plans the care of
a discipline and a profession. The goal of the discipline specific patients for a period of 24 hours. The primary
nurse provides direct care to those patients when things, theoretical knowledge is gained, for example, by
working and is responsible for directing and supervising reading a manual.
their care in collaboration with other health care team
members. Option A: Theoretical knowledge teaches the
reasoning, techniques and theory of knowledge.
Option B: Practical knowledge is the knowledge that is
19. Paul Jake suffered a stroke and has difficulty acquired by day-to-day hands-on experiences. In other
swallowing. Which healthcare team member should be words, practical knowledge is gained through doing
consulted to assess the patient’s risk for aspiration? things; it is very much based on real-life endeavors and
tasks.
A. Respiratory therapist Option C: While theoretical knowledge may guarantee
B. Occupational therapist that you understand the fundamental concepts and have
C. Dentist know-how about how something works and its
D. Speech therapist mechanism, it will only get you so far, as, without
practice, one is not able to perform the activity as well as
Speech and language therapists provide assistance to he could.
clients experiencing swallowing and speech Option D: Practical knowledge guarantees that you are
disturbances. They assess the risk for aspiration and able to actually do something instead of simply knowing
recommend a treatment plan to reduce the risk. Speech- how to do it.
language pathologists (SLPs) work to prevent, assess, Option E: Theoretical and practical knowledge are
diagnose, and treat speech, language, social interconnected and complement each other — if one
communication, cognitive-communication, and knows exactly HOW to do something, one must be able
swallowing disorders in children and adults. to apply these skills and therefore succeed in practical
knowledge.
Option A: Respiratory therapists provide care for
patients with respiratory disorders. Respiratory
therapists interview and examine patients with breathing 21. The nurse recognizes that urinary elimination
or cardiopulmonary disorders. Respiratory therapists changes may occur even in healthy older adults
care for patients who have trouble breathing—for because of which of the following?
example, from a chronic respiratory disease, such as
asthma or emphysema. A. The bladder distends and its capacity increases.
Option B: Occupational therapists help patients regain B. Older adults ignore the need to void.
function and independence. Occupational therapists C. Urine becomes more concentrated.
treat injured, ill, or disabled patients through the D. The amount of urine retained after voiding
therapeutic use of everyday activities. They help these increases.
patients develop, recover, improve, as well as maintain
the skills needed for daily living and working. The capacity of the bladder may decrease with age but
Option C: Dentists diagnose and treat dental disorders. the muscle is weaker and can cause urine to be
Dentists remove tooth decay, fill cavities, and repair retained. Muscle changes and changes in the
fractured teeth. Dentists diagnose and treat problems reproductive system can affect bladder control. As the
with patients’ teeth, gums, and related parts of the volume of urine held by the bladder increases, so too
mouth. They provide advice and instruction on taking does the pressure therein. Wall pressure of 5 to 15 mm
care of the teeth and gums and on diet choices that Hg creates a sensation of bladder fullness while 30 mm
affect oral health. Hg and beyond is painful. The sensation of increasing
bladder fullness is conveyed to the spinal cord via the
pudendal and hypogastric nerves on both A-delta and C
20. Which of the following is/are an example(s) of nerve fibers.
theoretical knowledge? Select all that apply.
Option A: The bladder wall changes. The elastic tissue
A. Antibiotics are ineffective in treating viral becomes tough and the bladder becomes less stretchy.
infections. The bladder cannot hold as much urine as before. The
B. When you take a patient's blood pressure, the urethra can become blocked. In women, this can be due
patient's arm should be at heart level. to weakened muscles that cause the bladder or vagina
C. In Maslow's framework, physical needs are most to fall out of position (prolapse). In men, the urethra can
basic. become blocked by an enlarged prostate gland.
D. When drawing medication out of a vial, inject air into Option B: Older adults don’t ignore the urge to void and
the vial first. may have difficulty getting to the toilet in time. Bladder
E. Let the patient dangle his feet first before assisting capacity changes throughout one’s life. In children, an
him to stand or transfer. approximation of bladder volume can be calculated with
the formula: (years of age + 2) x 30 mL. By adulthood,
Theoretical knowledge consists of research findings, the average volume that a functional bladder can
facts (e.g., “Antibiotics are ineffective . . .” is a fact), comfortably hold is between 300 and 400 mL.
principles, and theories (e.g., “In Maslow’s framework . . Option C: The kidney becomes less able to concentrate
.” is a statement from a theory). Instructions for taking urine with age. Urination or micturition primarily
blood pressure and withdrawing medications are functions in the excretion of metabolic products and
examples of practical knowledge—what to do and how toxic wastes. The urinary tract also serves as a storage
to do it. While practical knowledge is gained by doing vessel of the waste filtered from the kidneys. Urine
stored in the bladder is released from the bladder 23. Which action represents the appropriate nursing
through the urethra upon a complex network of management of a client wearing a condom catheter?
neurological function.
A. Ensure that the tip of the penis fits snugly against the
end of the condom.
22. During the assessment of the client with urinary B. Check the penis for adequate circulation 30 min
incontinence, the nurse is most likely to assess for which after applying.
of the following? Select all that apply. C. Change the condom every 8 hours.
D. Tape the collecting tube to the lower abdomen.
A. Perineal skin irritation
B. Fluid intake of less than 1,500 mL/d The penis and condom should be checked 1/2 hour after
C. History of antihistamine intake application to ensure that it’s not too tight. and the tubing
D. Hx of UTI is taped to the leg or attached to a leg bag. Condom
E. A fecal impaction catheters are external urinary catheters that are worn
like a condom. They collect urine as it drains out of your
Urinary incontinence is the involuntary leakage of urine. bladder and send it to a collection bag strapped to your
This medical condition is common in the elderly, leg. They’re typically used by men who have urinary
especially in nursing homes, but it can affect younger incontinence (can’t control their bladder).
adult males and females as well. Urinary incontinence
can impact both patient health and quality of life. The Option A: A 1 in. space should be left between the
prevalence may be underestimated as some patients do penis and the end of the condom. Place the condom
not inform health care providers of having issues with over the tip of the penis and slowly unroll it until it gets to
urinary incontinence for various reasons. the base. Leave enough room at the tip (1 to 2 inches)
so it won’t rub against the condom.
Option A: The perineum may become irritated by the Option C: The condom is changed every 24h. Condom
frequent contact with urine. Approximately 13 million catheters should be replaced every 24 hours. Throw
Americans experience urinary incontinence. The away the old one unless it’s designed to be reusable.
prevalence is 50% or greater among residents of The collection bag should be emptied when it’s about
nursing facilities. Caregivers report that 53% of the half full or at least every three to four hours for a small
homebound elderly are incontinent. A random sampling bag and every eight hours for a large one.
of hospitalized elderly patients reports that 11% of Option D: An indwelling catheter is taped to the lower
patients have persistent urinary incontinence at abdomen or upper thigh. Use a nonadhesive condom
admission, and 23% at discharge. catheter to help prevent irritation from adhesive. An
Option B: Normal fluid intake is at least 1,500 mL/d and inflatable ring holds it in place. Keep the bag lower than
clients often decrease their intake to try to minimize the bladder to avoid backflow of urine from the bag.
urine leakage. Functional urinary incontinence is the Securely attach the tube to the leg (below the knee,
involuntary leakage of urine due to environmental or such as the calf), but leave a little slack so it doesn’t pull
physical barriers to toileting. This type of incontinence is on the catheter.
sometimes referred to as toileting difficulty.
Option C: Antihistamines can cause urinary retention
rather than urinary incontinence. The urethra is the tube 24. The catheter slips into the vagina during a straight
that takes urine from the bladder out of the body. The catheterization of a female client. The nurse does which
problem can also be caused by using drugs such as action?
antihistamines (like Benadryl®), antispasmodics (like
Detrol®), and tricyclic antidepressants (like Elavil®) that A. Leaves the catheter in place and gets a new
can change the way the bladder muscle works. sterile catheter.
Option D: UTIs can contribute to incontinence. Patients B. Leaves the catheter in place and asks another nurse
should be asked about medical conditions such as to attempt the procedure.
chronic obstructive pulmonary disease and asthma C. Removes the catheter and redirects it to the urinary
(which can cause cough), heart failure (with related fluid meatus.
overload and diuresis), neurologic conditions (which D. Removes the catheter, wipes it with a sterile gauze,
may suggest dysregulated bladder innervation), and redirects it to the urinary meatus.
musculoskeletal conditions (which may contribute to
toileting barriers), etc. The catheter in the vagina is contaminated and can’t be
Option E: A fecal impaction can compress the urethra, reused. If left in place, it may help avoid mistaking the
which results in sm. amts of urine leakage. Overflow vaginal opening for the urinary meatus. A single failure
urinary incontinence is the involuntary leakage of urine to catheterize the meatus doesn’t indicate that another
from an overdistended bladder due to impaired detrusor nurse is needed although sometimes a second nurse
contractility and/or bladder outlet obstruction. Neurologic can assist in visualization of the meatus. Urinary bladder
diseases such as spinal cord injuries, multiple sclerosis, catheterization is performed for both therapeutic and
and diabetes can impair detrusor function. Bladder outlet diagnostic purposes. Based on the dwell time, the
obstruction can be caused by external compression by urinary catheter can be either intermittent (short-term) or
abdominal or pelvic masses and pelvic organ prolapse, indwelling (long-term).
among other causes. A common cause in men is benign
prostatic hyperplasia. Option B: After exposing the urethral meatus, a
lubricated catheter tip is advanced in the meatus until
there is a spontaneous return of urine. The catheter
balloon is then inflated as per the manufacturer’s 26. During shift report, the nurse learns that an older
recommendations. female client is unable to maintain continence after she
Option C: In the event a catheter is inserted in the senses the urge to void and becomes incontinent on the
vagina, it should be left there until a new sterile catheter way to the bathroom. Which nursing diagnosis is most
is successfully inserted into the meatus. Analgesia is of appropriate?
no proven clinical use in women. Lubrication jelly should
be applied to the tip of the catheter. The application of A. Stress urinary incontinence
lubricant to the urethral meatus is associated with B. Reflex urinary incontinence
difficulty in catheter insertion. C. Functional urinary incontinence
Option D: Urinary tract infection (UTI) is the most D. Urge urinary incontinence
common complication that occurs as a result of long-
term catheterization. The normal urinary flow prevents The key phrase is “the urge to void” option one occurs
the ascension of microbes from the periurethral skin when the client coughs, sneezes, or jars the body,
avoiding the infection. Alteration of the defensive resulting in accidental loss of urine. If one feels a strong
mechanism from the catheter results in an increased risk urge to urinate even when the bladder isn’t full, the
of UTIs. Escherichia coli and Klebsiella pneumonia are incontinence might be related to overactive bladder,
the most common organisms implicated in UTIs. sometimes called urge incontinence. This condition
Recurrent UTIs are associated with increased antibiotic occurs in both men and women and involves an
resistance. overwhelming urge to urinate immediately, frequently
followed by loss of urine before the client can reach a
bathroom. Even if one never has an accident, urgency
25. Which statement indicates a need for further and urinary frequency can interfere with work and a
teaching of a home care client with a long term social life because of the need to keep running to the
indwelling catheter? bathroom.

A. "I will keep the collecting bag below the level of the Option A: Stress Urinary Incontinence (SUI) is when
bladder at all times." urine leaks out with sudden pressure on the bladder and
B. "Intake of cranberry juice may help decrease the risk urethra, causing the sphincter muscles to open briefly.
of infection." With mild SUI, pressure may be from sudden forceful
C. "Soaking in a warm tub bath may ease the activities, like exercise, sneezing, laughing, or coughing.
irritation associated with the catheter." Option B: Reflex urinary incontinence occurs with
D. "I should use clean tech. when emptying the involuntary loss of urine at somewhat predictable
collecting bag." intervals when a specific bladder volume is reached.
Reflex incontinence occurs when the bladder muscle
Soaking in a bathtub can increase the risk of exposure contracts and urine leaks (often in large amounts)
to bacteria. Avoid taking baths, but shower daily. For the without any warning or urge. This can happen as a
first few days after getting a suprapubic catheter, use a result of damage to the nerves that normally warn the
waterproof bandage when showering. Once the wound brain that the bladder is filling.
heals, the client can shower as usual, but avoid scented Option C: Functional urinary continence is the
soaps. involuntary loss of urine related to impaired function. If
the urinary tract is functioning properly but other
Option A: The bag should be below the level of the illnesses or disabilities are preventing one from staying
bladder to promote proper drainage. Always keep the dry, the client might have what is known as functional
bag below the waist. Check the tube once in a while for incontinence. For example, if an illness rendered the
bends or kinks that keep pee from flowing out. Don’t use client unaware or unconcerned about the need to find a
any lotions or powders around where the catheter goes toilet, the client would become incontinent. Medications,
into the body. dementia, or mental illness can decrease awareness of
Option B: Intake of cranberry juice creates an the need to find a toilet.
environment nonconducive to infection. “Indwelling”
means inside the body. This catheter drains urine from
the bladder into a bag outside the body. Common 27. A female client has a urinary tract infection. Which
reasons to have an indwelling catheter are urinary teaching points by the nurse should be helpful to the
incontinence (leakage), urinary retention (not being able client? Select all that apply.
to urinate), a surgery that made this catheter necessary,
or another health problem. A. Limit fluids to avoid the burning sensation on
Option D: Clean technique is appropriate for touching urination.
the exterior portions of the system. Wash hands with B. Review symptoms of UTI with the client.
soap and water. Empty urine from the bag into the toilet. C. Wipe the perineal area from back to front.
Pinch the catheter closed between the fingers. Remove D. Wear cotton underclothes.
the bag. Wipe the end of the catheter with a fresh E. Take baths rather than showers.
alcohol pad. Wipe the tip of the new bag with the second
alcohol pad. Connect the new bag and stop pinching the Uncomplicated urinary tract infection (UTI) is a bacterial
catheter now. Make sure there are no bends or kinks in infection of the bladder and associated structures.
the catheter tube. Wash hands again. These are patients with no structural abnormality and no
comorbidities, such as diabetes, immunocompromised,
or pregnant. Uncomplicated UTI is also known as cystitis
or lower UTI. Forty percent of women in the United
States will develop a UTI during their lifetime, making it created from the terminal ileum. The ureters are
one of the most common infections in women. UTI is disconnected from the bladder and implanted into the
uncommon in circumcised males, and by definition, any conduit.
male UTI is considered complicated. Option C: Clients with a neobladder can control their
voiding. During neobladder surgery, the surgeon takes
Option A: Increased fluids decrease concentration and out the existing bladder and forms an internal pouch
irritation. An uncomplicated UTI usually only involves the from part of the intestine. The pouch, called a
bladder. When the bacteria invade the bladder mucosal neobladder, stores the urine.
wall, cystitis is produced. The majority of organisms Option D: A vesicostomy is a stoma (opening) created
causing a UTI are enteric coliforms that usually inhabit between the bladder and the abdomen. This allows
the periurethral vaginal introitus. These organisms urine to drain freely, with low pressure, to help protect
ascend into the bladder and cause a UTI. and prevent harm to the kidneys. It is a surgical
Option B: Reviewing the symptoms of UTI with the procedure that typically involves an overnight stay in the
client validates the diagnosis. Symptoms of hospital.
uncomplicated UTI are pain on urination (dysuria),
frequent urination (frequency), inability to start the urine
stream (hesitation), sudden onset of the need to urinate 29. Which focus is the nurse most likely to teach for a
(urgency), and blood in the urine (hematuria). Usually, client with a flaccid bladder?
patients with uncomplicated UTI do not have fever,
chills, nausea, vomiting, or back pain, which are signs of A. Habit training: attempt voiding at specific time
kidney involvement or upper tract periods.
disease/pyelonephritis. B. Bladder training: delay voiding according to a pre-
Option C: The client should wipe the perineal area from schedule timetable.
front to back to prevent the spread of bacteria from the C. Crede's maneuver: apply gentle manual pressure
rectal area to the urethra. Sexual intercourse is a to the lower abdomen.
common cause of a UTI as it promotes the migration of D. Kegel exercises: contract the pelvic muscles.
bacteria into the bladder. People who frequently void
and empty the bladder have a much lower risk of a UTI. Because the bladder muscles will not contract to
Option D: Cotton underwear promotes appropriate increase the intra-bladder pressure to promote urination,
exposure to air, resulting in decreased bacterial growth. the process is initiated manually. The Credé maneuver
Urine is an ideal medium for bacterial growth; factors is a technique used to void urine from the bladder of an
that make it unfavorable for bacterial growth include a individual who, due to disease, cannot do so without aid.
pH of less than 5, presence of organic acids, and high The Credé maneuver is executed by exerting manual
levels of urea. Frequent urination is also known to pressure on the abdomen at the location of the bladder,
decrease the risk of UTI. just below the navel. Options one, two, and four: to
Option E: Showers reduce exposure of the area to promote continence bladder contractions are required
bacteria. Bacteria that cause UTI have adhesins on their for habit training, bladder training, and increasing the
surface which allow the organism to attach to the tone of the pelvic muscles.
mucosal surface. In addition, a short urethra also makes
it easier for the uropathogen to invade the urinary tract. Option A: One type of toilet training is habit training.
Habit training is the process of teaching a child to
eliminate on the toilet at routine times. Habit training
28. The nurse will need to assess the client’s involves teaching children to eliminate on the toilet by
performance of clean intermittent self catheterization developing a toileting routine/habit.
(CISC) for a client with which urinary diversion? Option B: Bladder training is an important form of
behavior therapy that can be effective in treating urinary
A. Ileal conduit incontinence. The goals are to increase the amount of
B. Kock pouch time between emptying your bladder and the amount of
C. Neobladder fluids your bladder can hold. It also can diminish leakage
D. Vesicostomy and the sense of urgency associated with the problem.
Option D: Kegel exercises can help make the muscles
The ileal conduit and vesicostomy are incontinent under the uterus, bladder, and bowel (large intestine)
urinary diversions, and clients are required to use an stronger. They can help both men and women who have
external ostomy appliance to contain the urine. In this problems with urine leakage or bowel control.
new operation, a pouch or reservoir is fashioned out of
the terminal ileum with a valve mechanism at its exit to
the skin surface. This allows storage of the liquid bowel 30. Which of the following behaviors indicates that the
contents in an expandable container with no leakage of client on a bladder training program has met the
stool or gas and therefore no skin problems. There is no expected outcomes? Select all that apply.
need for appliances or bags, no embarrassment from
the involuntary noise and smell of flatus through the A. Voids each time there is an urge.
ileostomy. The stoma is created flush and within the B. Practices slow, deep breathing until the urge
bikini line. The patient catheterizes the pouch on an decreases.
average of three times a day. C. Uses adult diapers, for "just in case".
D. Drinks citrus juices and carbonated beverages.
Option A: An ileal conduit aims to divert urine produced E. Performs pelvic muscle exercises.
from the upper urinary tracts to a newly formed reservoir
It is important for the client to inhibit the urge to void type of urinary incontinence often do not feel that their
sensation when a premature urge is experienced. bladders are full, which then leads to leakage as the
Bladder training, a program of urinating on schedule, bladder has reached its full capacity. In addition to
enables the client to gradually increase the amount of leakage, urine left in the bladder can lead to urinary tract
urine the client can comfortably hold. Bladder training is infections due to the growth of bacteria as well as
a mainstay of treatment for urinary frequency and bladder stones.
overactive bladder in both women and men, alone or in
conjunction with medications or other techniques.
32. A nurse must measure the intake and output (I&O)
Option A: Choose an interval. Based on the typical for a patient who has a urinary retention catheter. Which
interval between urinations, select a starting interval for equipment is most appropriate to use to accurately
training that is 15 minutes longer. If the typical interval is measure urine output from a urinary retention catheter?
one hour, make a starting interval one hour and 15
minutes. A. Urinal
Option B: When the client starts training, he should B. Graduate
empty his bladder first thing in the morning and not C. Large syringe
again until the interval he set. If the time arrives before D. Urine collection bag
he can feel the urge, he should go anyway. If the urge
hits first, he should remind himself that his bladder isn’t A graduate is a collection container with volume
really full, and use whatever techniques he can to delay markings usually at 25 mL increments that promote
going. accurate measurements of urine volume. To measure
Option C: Some clients may need diapers; this is not urine output in critical care units, a Foley catheter is
the best indicator of a successful program. introduced through the patient’s urethra until it reaches
Option D: Citrus juices may irritate the bladder. his/her bladder. The other end of the catheter is
Carbonated beverages increase diuresis and the risk of connected to a graduated container that collects the
incontinence. urine.
Option E: Try the pelvic floor exercises sometimes
called Kegels, or simply try to wait another five minutes Option A: Although urinals have volume markings on
before walking slowly to the bathroom. Once the side, usually they occur in 100 mL increments that
comfortable with a set interval, increase it by 15 do not promote accurate measurements. Urine output is
minutes. Over several weeks or months, the client may the best indicator of the state of the patient’s kidneys. If
find that they are able to wait much longer and that they the kidneys are producing an adequate amount of urine
have experienced far fewer feelings of urgency or it means that they are well perfused and oxygenated.
episodes of urge incontinence. Otherwise, it is a sign that the patient is suffering from
some complications.
Option C: Large syringe is impractical. A large syringe
31. A nurse has identified that the patient has overflow is used to obtain a sterile specimen from a retention
incontinence. What is a major factor that contributes to catheter (Foley catheter). Urine output is required for
this clinical manifestation? calculating the patient’s water balance, which is
essential in the treatment of burn patients. Finally, it is
A. Coughing also used in multiple therapy protocols to check whether
B. Mobility deficits the patient reacts properly to treatment
C. Prostate enlargement Option D: A urine collection bag is flexible and balloons
D. Urinary tract infection outward as urine collects. In addition, the volume
markings are at 100 mL increments that do not promote
An enlarged prostate compresses the urethra and accurate measurements. In critical care units of first
interferes with the outflow of urine, resulting in urinary world countries, measurements of every patient’s urine
retention. With urinary retention, the pressure within the output are taken hourly, 24 times a day, 365 days a
bladder builds until the external urethral sphincter year. In the case of emerging countries, often only burn
temporarily opens to allow a small volume (25-60mL) of patients—for whom urine output monitoring is of
urine to escape (overflow incontinence). Men who are paramount importance—have this parameter recorded
unable to completely empty their bladder and every hour, while the remaining critical patients have it
experience unexpected urine leakage may have what is recorded every 2 or 3 hours.
called overflow incontinence.

Option A: Coughing, which raises the intra abdominal 33. A patient’s urine is cloudy, is amber, and has an
pressure, is related to stress incontinence, not overflow unpleasant odor. What problem may this information
incontinence. An enlarged prostate can interfere with the indicate that requires the nurse to make a focused
passage of urine through the urethra, the tube assessment?
connected to the bladder.
Option B: Mobility deficits, such as spinal cord injuries, A. Urinary retention
are related to reflex incontinence, not overflow B. Urinary tract infection
incontinence. Damage to nerves near the bladder C. Ketone bodies in the urine
causing under-activity. This can occur with neurological D. High urinary calcium level
injury or with diseases such as diabetes.
Option D: Urinary tract infections are related to urge The urine appears concentrated (amber)and cloudy
incontinence, not overflow incontinence. Men with this because of the presence of bacteria, white blood cells,
and red blood cells. The unpleasant odor is caused by efficacious both when used alone or together with
pus in the urine (pyuria). Uncomplicated urinary tract pharmacological therapy in controlling nocturia.
infection (UTI) is a bacterial infection of the bladder and Option B: Assisting with toileting may be too often or
associated structures. These are patients with no not often enough for the patient. Care should be
structural abnormality and no comorbidities, such as individualized for the patient. In particular, older adults
diabetes, immunocompromised, or pregnancy. with nocturia who make multiple nocturnal trips to the
Uncomplicated UTI is also known as cystitis or lower bathroom are at a substantially increased risk of
UTI. potentially serious falls. A quarter of all the falls that
occur in older individuals happen overnight. Of these,
Option A: These clinical manifestations do not reflect 25% are directly related to nocturia. Patients who make
urinary retention. Urinary retention is evidenced by at least 2 or more nocturnal bathroom visits a night,
supra pubic distention and lack of voiding or small, have more than double the risk of fractures and fall-
frequent voiding (overflow incontinence). The related traumas.
mechanisms of acute urinary retention can include Option D: Fluids may be decreased during the last two
outflow obstruction, which can be mechanical such as hours before bedtime, but they should not be avoided
from physical narrowing of the urethral channel. The completely after 5 PM (opt4). Some fluid intake is
other dynamic is from an increase in the muscle tone necessary for adequate renal perfusion. Drinking large
within and around the urethra as in benign prostatic amounts of fluids shortly before going to bed and
hypertrophy and hyperplasia. ingesting caffeine or alcohol late in the day and before
Option C: These clinical manifestations do not reflect bed is likely to contribute to nocturia as well. Be aware
ketone bodies in the urine. A reagent strip dipped in that some elderly patients may already be somewhat
urine will measure the presence of Ketone bodies. If the dehydrated and might require extra fluid intake earlier in
cells don’t get enough glucose, the body burns fat for the day before they can safely do any evening fluid
energy instead. This produces a substance called restriction before bedtime.
ketones, which can show up in the blood and urine.
Option D: These clinical manifestations do not reflect
excessive calcium in the urine. Urine calcium levels are 35. A practitioner uses a urine specimen for culture and
measured by assessing a 24-hour urine specimen. If sensitivity via a straight catheter for a patient. What
urine calcium levels are too high or too low, it may mean should the nurse do when collecting this urine
that the client has a medical condition, such as kidney specimen?
disease or kidney stones. Kidney stones are hard,
pebble-like substances that can form in one or both A. Use a sterile specimen container.
kidneys when calcium or other minerals build up in the B. Collect urine from the catheter port.
urine. Most kidney stones are formed from calcium. C. Inflate the balloon with 10 mL of sterile water.
D. Have the patient void before collecting the specimen.

34. A nurse is caring for a debilitated female patient with A culture attempts to identify the microorganisms
nocturia. Which nursing intervention is the priority when present in the urine, and a sensitivity study identifies the
planning to meet this patient’s needs? antibiotics that are effective against the isolated
microorganisms. A sterile specimen container is used to
A. Encouraging the use of bladder training exercises. prevent contamination of the specimen by
B. Providing assistance with toileting every four hours. microorganisms outside the body (exogenous).
C. Positioning a bedside commode near the bed.
D. Teaching the avoidance of fluid after 5 PM. Option B: The urine from the straight catheter flows
directly into the specimen container. Collecting a urine
The use of a commode requires less energy than using specimen from a catheter port is necessary when the
a bedpan and is safer than walking to the bathroom. patient has a urinary retention catheter. A straight
Sitting on the commode uses gravity to empty the catheter has a single lumen for draining urine from the
bladder fully and thus prevent urinary stasis. Nocturia is bladder.
defined as the need for a patient to get up at night on a Option C: A straight catheter does not remain in the
regular basis to urinate. A period of sleep must precede bladder and therefore does not have a 2nd lumen for
and follow the urinary episode to count as a nocturnal water to be inserted into a balloon. This may result in no
void. This means the first-morning void is not considered urine left in the bladder for the straight catheter to
when determining nocturia episodes. Use of a bedside collect.
commode or urinal can minimize the bother, if not the Option D: A minimum of 3 mL of urine is necessary for
frequency, of nocturia and may reduce the risk of falls. a specimen for urine culture and sensitivity. Do not
Remove any obstacles, loose rugs, or furniture between urinate for at least 1 hour before the test. If the client
the bed and the nearest commode to reduce fall risk doesn’t have the urge to urinate, he may be instructed to
further. Consider using nightlights to help illuminate the drink a glass of water 15 to 20 minutes before the test.
passage to the bathroom. Otherwise, there is no preparation for the test.

Option A: Although bladder training exercises should be

done, it is not the priority. Behavioral therapy, which 36. A nurse in a provider’s office is assessing a client
includes pelvic floor muscle training, urge-suppression who reports losing control of urine whenever she
techniques, delayed voiding, fluid management, sleep coughs, laughs, or sneezes. The client relates a history
hygiene, Kegel exercises, and peripheral edema of three vaginal births, but no serious accidents or
management, has been shown to be reasonably illnesses. Which of the following interventions are
appropriate for helping to control or eliminate the clients catheter (IUC), generally referred to as a “Foley”
incontinence? Select all that apply. catheter, is a closed sterile system with a catheter and
retention balloon that is inserted either through the
A. Limit total daily fluid intake urethra or suprapubically to allow for bladder drainage.
B. Decrease or avoid caffeine External collecting devices (e.g. drainage tubing and
C. Increase the intake of calcium supplements bag) are connected to the catheter for urine collection.
D. Avoid the intake of alcohol
E. Use Crede maneuver Option B: Reassuring the client that it is not possible to
urinate is a non-therapeutic response because it
Caffeine and alcohol are bladder irritants and can diminishes the client’s concern. Check the tube once in
worsen stress incontinence. Alcohol is a bladder irritant a while for bends or kinks that keep pee from flowing
and can worsen stress incontinence. Quitting smoking, out. Empty the leg bag twice a day or when it’s half full.
losing excess weight, or treating a chronic cough will Keep the drainage bag below your bladder so it drains
lessen the risk of stress incontinence and improve the well.
symptoms. Stress incontinence is different from urgency Option C: There are less invasive approaches the nurse
incontinence and overactive bladder (OAB). If the client can take before replacing the catheter. Indwelling
has urgency incontinence or OAB, the bladder muscle urinary catheters are recommended only for short-term
contracts, causing a sudden urge to urinate before he use, defined as less than 30 days (EAUN recommends
can get to the bathroom. Stress incontinence is much no longer than 14 days.) The catheter is inserted for
more common in women than in men. continuous drainage of the bladder for two common
bladder dysfunction: urinary incontinence (UI) and
Option A: Because stress incontinence results from urinary retention.
weak pelvic muscles and other structures, limiting fluid Option D: Although it may become necessary to collect
will not resolve the problem. The doctor may a urine specimen, there is a simpler approach the nurse
recommend how much and when one should consume can take to assess and possibly resolve the client’s
fluids during the day and evening. However, don’t limit problem.
what the client drinks so much that he becomes
dehydrated.
Option B: Lifestyle changes should be made such as 38. A provider prescribes a 24-hour urine collection for a
reducing caffeine intake (including green tea), stopping client. Which of the following actions should the nurse
smoking, and losing weight. take?
Option C: Calcium has no effect on stress incontinence.
Bladder training involves learning techniques to increase A. Discard the first voiding.
the length of time between feeling the need to urinate B. Keep all voidings in a container at room temperature.
and passing urine. The course usually lasts for at least C. Ask the client to urinate and pour the urine into a
six weeks and can be combined with the Kegel specimen container.
exercises. Some individuals may find that timed toileting D. Ask the client to urinate into the toilet, stop
is helpful, particularly for people with a learning disability midstream, and finish urinating into the specimen
or cognitive impairment. container.
Option D: The doctor may also suggest that the client
avoid caffeinated, carbonated, and alcoholic beverages, The nurse should discard the first voiding of the 24 hour
which may irritate and affect bladder function in some urine specimen, and note the time. 24-hour urine protein
people. If he finds that using fluid schedules and measures the amount of protein released in urine over a
avoiding certain beverages significantly improves 24-hour period. The normal value is less than 100
leakage, the client will have to decide whether making milligrams per day or less than 10 milligrams per
these changes in the diet are worth it. deciliter of urine.
Option E: The Crede maneuver helps manage reflex
incontinence, not stress incontinence. Pelvic floor Option B: The nurse should collect all voidings after
muscle training is a technique that strengthens the that and keep them in a refrigerated container. A 24-
pelvic floor muscles and is an effective treatment for hour urine collection is done by collecting the urine in a
stress incontinence, especially if the muscle has been special container over a full 24-hour period. The
damaged. container must be kept cool until the urine is returned to
the lab.
Option C: For a urinalysis, the nurse should ask the
37. A client who has an indwelling catheter reports the client to urinate and pour the urine into a specimen
need to urinate. Which of the following interventions container. Urine is made up of water and dissolved
should the nurse perform? chemicals, such as sodium and potassium. It also
contains urea. This is made when protein breaks down.
A. Check to see whether the catheter is patent. And it contains creatinine, which is formed from muscle
B. Reassure the client that it is not possible for her to breakdown. Normally, urine contains certain amounts of
urinate. these waste products. It may be a sign of a certain
C. Re-catheterize the bladder with a larger gauge disease or condition if these amounts are not within a
catheter. normal range. Or if other substances are present.
D. Collect a urine specimen for analysis. Option D: For a culture, the nurse should ask the client
to urinate first into the toilet, then stop midstream, and
A clogged or kinked catheter causes the bladder to fill finish urinating in the specimen container. A 24-hour
and stimulates the need to urinate. An indwelling urinary urine collection helps diagnose kidney problems. It is
often done to see how much creatinine clears through following should be included in the review? Select all
the kidneys. It’s also done to measure protein, that apply.
hormones, minerals, and other chemical compounds.
A. Having sexual intercourse on a frequent basis.
B. Lowering of testosterone levels.
39. A nurse is preparing to initiate a bladder training C. Wiping from front to back.
program for a client who has a voiding disorder. Which D. The location of the vagina in relation to the anus.
of the following actions should the nurse take? Select all E. Undergoing frequent catheterization.
that apply.
Uncomplicated urinary tract infection (UTI) is a bacterial
A. Establish a schedule of voiding prior to meal times. infection of the bladder and associated structures.
B. Have the client record voiding times. These are patients with no structural abnormality and no
C. Gradually increase the voiding intervals. comorbidities, such as diabetes, immunocompromised,
D. Reminded client to hold urine until next or pregnancy. Uncomplicated UTI is also known as
scheduled voiding time. cystitis or lower UTI. E.coli causes the majority of UTI
E. Provide a sterile container for voiding. but other organisms of importance include proteus,
klebsiella, and enterococcus. The diagnosis of UTI is
Ask the client to keep track of voiding times is an made from the clinical history and urinalysis, but the
appropriate nursing action. Gradually increasing the proper collection of the urine sample is important.
voiding interval is an appropriate nursing action. The
client should be reminded to hold urine until the next Option A: Having sexual intercourse on a frequent
scheduled voiding time. Bladder training involves voiding basis is a factor that increases the risk of UTI in both
at scheduled in frequent intervals and gradually males and females. Sexual intercourse and the use of
increasing these intervals to four hours. spermicide and diaphragm are also risk factors for UTI.
Sexual intercourse is a common cause of a UTI as it
Option A: Mealtimes are not regular, and the intervals promotes the migration of bacteria into the bladder.
may be longer than every four hours. Bladder training People who frequently void and empty the bladder have
requires following a fixed voiding schedule, whether or a much lower risk of a UTI.
not one feels the urge to urinate. If one feels an urge to Option B: The decrease in estrogen levels during
urinate before the assigned interval, he should use urge menopause increases a woman’s susceptibility to UTIs.
suppression techniques — such as relaxation and Kegel An uncomplicated UTI usually only involves the bladder.
exercises. When the bacteria invade the bladder mucosal wall,
Option B: Keeping a diary of bladder activity is very cystitis is produced. The majority of organisms causing a
important. This helps the health care provider determine UTI are enteric coliforms that usually inhabit the
the correct place to start the training and to monitor periurethral vaginal introitus. These organisms ascend
progress throughout the program. into the bladder and cause a UTI.
Option C: Bladder training is an important form of Option C: Wiping from front to back decreases a
behavior therapy that can be effective in treating urinary woman’s risk of UTIs. After urination, women should
incontinence. The goals are to increase the amount of wipe from front to back, not from the anal area forward,
time between emptying the bladder and the amount of which seems to drag pathogenic organisms nearer to
fluids the bladder can hold. It also can diminish leakage the urethra. Bacteria that cause UTI have adhesins on
and the sense of urgency associated with the problem. their surface which allow the organism to attach to the
Option D: When the client feels the urge to urinate mucosal surface. In addition, a short urethra also makes
before the next designated time, he should use “urge it easier for the uropathogen to invade the urinary tract.
suppression” techniques or try relaxation techniques like Premenopausal women have large concentrations of
deep breathing. Focus on relaxing all other muscles. If lactobacilli in the vagina and prevent the colonization of
possible, he must sit down until the sensation passes. If uropathogens. However, the use of antibiotics can erase
the urge is suppressed, adhere to the schedule. If the this protective effect.
client cannot suppress the urge, wait five minutes then Option D: The close proximity of the female urethra to
slowly make way to the bathroom. After urinating, re- the anus is a factor that increases the risk of UTIs.
establish the schedule. Repeat this process every time Pathogenic bacteria ascend from the perineum, causing
an urge is felt. UTI. Women have shorter urethras than men and
Option E: A sterile container is not used in a bladder therefore are more susceptible to UTI. Very few
training program. When the client has accomplished the uncomplicated UTIs are caused by blood-borne
initial goal, he should gradually increase the time bacteria. Escherichia coli is the most common organism
between emptying the bladder by 15-minute intervals. in uncomplicated UTI by a large margin.
He should try to increase the interval each week. Option E: Undergoing frequent catheterization and the
However, he will be the best judge of how quickly he can use of indwelling catheters are risk factors for UTIs. A
advance to the next step. Increase the time between major risk factor for UTI is the use of a catheter. In
each urination until he reaches a three- to four-hour addition, manipulation of the urethra is also a risk factor.
voiding interval. In-and-out catheterization of the bladder will cause UTI
in uninfected women 1% of the time. Men should start
the urine stream to clean the urethra and then obtain a
40. A nurse educator on a medical unit is reviewing midstream sample. Urine should be sent to the lab
factors that increase the risk of urinary tract infections immediately or refrigerated because bacteria grow
with a group of assistive personnel. Which of the rapidly when a sample is left at room temperature,
causing an overestimate of the infection’s severity.
 tracheostomy tube. With the increasing number of
patients with tracheostomy, safe caring requires
41. To prevent postoperative complications, Nurse Kim knowledge and competencies in dealing with routine
assists the client with coughing and deep breathing care, weaning, decannulation, as well as tracheostomy-
exercises. This is best accomplished by implementing related emergencies.
which of the following?
Option B: The twill tape is not changed until after
A. Coughing exercises one hour before meals and deep performing tracheostomy care. Remove any sutures or
breathing one hour after meals. ties attached to the tracheostomy tube and patient.
B. Forceful coughing as many times as tolerated. When doing this, the assistant must stabilize the flange
C. Huff coughing every two hours or as needed. at all times to prevent premature removal.
D. Diaphragmatic and pursed lip breathing 5 to 10 Option C: Cleaning the incision should be done after
times, four times a day. cleaning the inner cannula. Inspect the stoma for signs
of infection, presence of granulation tissue, bleeding,
Huff coughing helps keep the airways open and wound breakdown, and adequacy of a tract. Clean the
secretions mobilized. Huff coughing is an alternative for area with moist gauze (with normal saline or hydrogen
clients who are unable to perform a normal forceful peroxide) followed by dry gauze while ensuring no
cough (such as postoperatively) deep breathing and foreign body enters the airway. Stay sutures, if present,
coughing should be performed at the same time. may be used gently to pull up the trachea to provide
exposure.
Option A: Only at mealtimes is not sufficient. Deep Option D: Checking the tightness of the ties and knot is
breathing and coughing exercises can decrease the risk done after applying new twill tape. Make sure the trach
of lung complications following surgery. Not only can ties are not too tight and should be able to pass an index
they prevent pneumonia, deep breathing helps to get finger in between the trach ties and neck.
more oxygen to the body’s cells. These exercises can
also be beneficial to individuals who are susceptible to
pulmonary or respiratory problems. Coughing and deep 43. Which action by the nurse represents proper
breathing work to clear mucus and allow moist air to nasopharyngeal/nasotracheal suctioning technique?
enter the airways.
Option B: Extended forceful coughing fatigues the A. Lubricate the suction catheter with petroleum jelly
client, especially postoperatively. If you are lying in bed before and between insertion.
and need to cough, it may be more comfortable to bend B. Apply suction intermittently while inserting the
your knees up. Lean forward when you cough, if you are suction catheter.
sitting in a chair. Place a pillow over your surgical C. Rotate the catheter while applying suction.
incision and apply pressure to the area while coughing. D. Hyper oxygenate with 100% oxygen for 30 minutes
This can help to alleviate any discomfort you feel. It’s before and after suctioning.
more comfortable to sit upright if you can when doing
coughing exercises. Rotating the catheter prevents pulling of tissue into the
Option D: Diaphragmatic and pursed-lip breathing are opening on the catheter tip and the side. Suction is used
techniques used for clients with obstructive airway to clear retained or excessive lower respiratory tract
disease. You can perform breathing exercises by secretions in patients who are unable to do so effectively
relaxing your shoulders and upper chest. Take a deep for themselves. This could be due to the presence of an
breath in through your nose. Hold the breath for three artificial airway, such as an endotracheal or
seconds. Breathe out slowly through your mouth. tracheostomy tube, or in patients who have a poor
Repeat three times. Taking too many breaths can make cough due to an array of reasons such as excessive
you dizzy or light-headed. Perform breathing exercises sedation or neurological involvement.
every hour.
Option A: Suction catheters may only be lubricated with
water or water-soluble lubricant and petroleum jelly such
42. Nurse Trixie is preparing to perform tracheostomy as Vaseline has an oil base. Lubricate the outside of the
care. Prior to the beginning of the procedure, the nurse airway with a water-soluble/aqueous gel (e.g. KY Jelly).
performs which action? Initially, choose the larger nostril that is clear from other
tubes (e.g. nasogastric tube). Insert the tip of the NPA
A. Tells the client to raise two fingers to indicate into the nostril, then slightly lift the nares up and direct
pain or distress. the airway to follow a path along the floor of the nose,
B. Changes twill tape holding the tracheostomy and parallel to the hard palate.
place. Option B: No suction should ever be applied while the
C. Cleans the incision site. catheters are being inserted because this can
D. Check the tightness of the ties and knot. traumatize tissues. Apply a gentle partial rotation to the
NPA if resistance is felt during insertion e.g. from
Prior to starting the procedure, it is important to develop opposition against the turbinates. If this does not relieve
a means of communication by which the client can the resistance/obstruction then withdraw the airway and
express pain or discomfort. Tracheostomy is a try the other nostril before selecting a smaller size.
procedure where an artificial airway is established Option D: The client should be hyper-oxygenated for
surgically or percutaneously in the cervical trachea. The only a few minutes before and after suctioning and this
term “tracheostomy” has evolved to refer to both the is generally limited to clients who are intubated or have
procedure as well as the clinical condition of having a a tracheostomy. Hyper-oxygenate the patient if able
(increase mask flow rate or FiO2) delivery of 100% The tube should be reconnected to the water seal as
oxygen for > 30 secs prior to the suction event. quickly as possible. Assisting the client back to bed and
assessing the client’s lung are possible actions after the
system is reconnected. Or place the end of the tube in a
44. Which client statement informs the nurse that his bottle of sterile water, creating a water seal. Instruct a
teaching about the proper use of an incentive spirometer colleague to prepare a new sterile chest-drainage
was effective? collection device, or retrieve a new sterile connector
while safely returning the patient to bed. Observe the
A. "I should breathe out as fast and as hard as possible patient for signs and symptoms of respiratory decline.
into the device." Then reconnect the chest tube to the new drain and
B. "I should inhale slowly and steadily to keep the unclamp it.
balls up."
C. "I should use the device three times a day, after Option A: If walking with the patient and the chest tube
meals." becomes dislodged where it connects to the drainage
D. "The entire device should be washed thoroughly in tubing, immediately close off the tubing to air with a
sudsy water once a week." gloved hand by crimping it or using a clamp, if readily
available.
Proper use of an SMI requires the client to take slow, Option C: Whether chest-tube removal was planned or
steady inhalations, every hour or two, 5 to 10 reps each unplanned, monitor the patient closely for signs and
time. Spirometry is one of the most readily available and symptoms of respiratory compromise, using such
useful tests for pulmonary function. It measures the techniques as pulse oximetry (Spo2), end-tidal carbon
volume of air exhaled at specific time points during dioxide (ETco2) monitoring, and breath sound
complete exhalation by force, which is preceded by a auscultation.
maximal inhalation. The most important variables Option D: Monitor the patient’s respiratory rate and
reported include total exhaled volume, known as the effort. A repeat chest X-ray (if indicated) may be done to
forced vital capacity (FVC), the volume exhaled in the compare to previous films and evaluate for presence or
first second, known as the forced expiratory volume in return of a pneumothorax, an effusion, or other problem.
one second (FEV1), and their ratio (FEV1/FVC).

Option A: The patient must breathe in as much air as 46. Nurse Peter makes the assessment that which client
they can with a pause lasting for less than 1s at the total has the greatest risk for a problem with the transport of
lung capacity. The mouthpiece is placed just inside the oxygen from the lungs to the tissues? A client who has:
mouth between the teeth, soon after the deep inhalation.
The lips should be sealed tightly around the mouthpiece A. Anemia
to prevent air leakage. Exhalation should last at least 6 B. An infection
seconds, or as long as advised by the instructor. If only C. A fractured rib
the forced expiratory volume is to be measured, the D. A tumor of the medulla
patient must insert the mouthpiece after performing step
1 and must not breathe from the tube. Anemia is a condition of decreased red blood cells and
Option C: The procedure is repeated in intervals decreased hemoglobin. Hemoglobin is how the oxygen
separated by 1 minute until two matching, and molecules are transported to the tissues. Anemia is
acceptable results are acquired. Spirometry has proved described as a reduction in the proportion of red blood
to be a crucial tool in diagnosing lung disease, cells. Anemia is not a diagnosis, but a presentation of an
monitoring patients for their pulmonary function, and underlying condition. Whether or not a patient becomes
assessing their fitness for various procedures. symptomatic depends on the etiology of anemia, the
Option D: Only the mouthpiece can be successfully acuity of onset, and the presence of other comorbidities,
rinsed or wiped clean. The device should not be especially the presence of cardiovascular disease.
submerged in water. Spirometry is an apparatus used to
assess pulmonary function for diagnostic or monitoring Option B: An infection would depend on its location.
purposes. The procedure must be explained thoroughly Infections can be caused by a variety of different
to the subject patient by competent personnel who organisms, including viruses, bacteria, fungi, and
underwent training under supervision by a specialist parasites. The different ways that you can get an
mentor and will undergo periodic retraining in order to infection can be just as diverse as the organisms that
ensure that the results obtained are as accurate as cause them.
possible and the complications are kept to a minimum. Option C: A fractured rib would interrupt the transport of
oxygen from the atmosphere to the airways. Broken ribs
are most commonly caused by direct impacts — such as
45. While a client with chest tubes is ambulating, the those from motor vehicle accidents, falls, child abuse, or
connection between the tube and the water seal contact sports. Ribs also can be fractured by repetitive
dislodges. Which action by Nurse Flora is most trauma from sports like golf and rowing or from severe
appropriate? and prolonged coughing.
Option D: Damage to the medulla would interfere with
A. Assist the client to ambulate back to bed. neural stimulation of the respiratory system. Tumors of
B. Reconnect the tube to the water seal. the medulla cause swallowing problems and limb
C. Assess the client's lung sounds with a stethoscope. weakness.
D. Have the client cough forcibly several times.
47. Which term does the nurse document to best expression and translation for inflammatory leukocytes
describe a client experiencing shortness of breath while and structural cells such as epithelium. This action leads
lying down who must assume an upright or sitting to a reduction in proinflammatory cytokines,
position to breathe more comfortably and effectively? chemokines, and cell adhesion molecules, as well as
other enzymes involved in the inflammatory response.
A. Dyspnea Option B: The non-genomic mechanism occurs more
B. Hyperpnea rapidly and is mediated through interactions between the
C. Orthopnea intracellular glucocorticoid receptor or a membrane-
D. Apnea bound glucocorticoid receptor. Within seconds to
minutes of receptor activation, a cascade of effects is
Respiratory difficulty related to a reclining position set off, including inhibition of phospholipase A2, which is
without other physical alterations is defined as critical for the production of inflammatory cytokines,
orthopnea. Orthopnea is the sensation of impaired release of arachidonic acid, and regulation of
breathlessness in the recumbent position, relieved by apoptosis in thymocytes.
sitting or standing. Orthopnea is caused by pulmonary Option C: Their nonendocrine role regularly takes
congestion during recumbency. In the horizontal position advantage of their potent anti-inflammatory and
there is redistribution of blood volume from the lower immunosuppressive effects to treat patients with a wide
extremities and splanchnic beds to the lungs. range of immunologic and inflammatory disorders.
Corticosteroids are used at physiologic doses as
Option A: Dyspnea is the medical term for shortness of replacement therapy in cases of adrenal insufficiency
breath, sometimes described as “air hunger.” It is an and supraphysiologic doses in treatments for anti-
uncomfortable feeling. Shortness of breath can range inflammatory and immunosuppressive effects.
from mild and temporary to serious and long-lasting. It is
sometimes difficult to diagnose and treat dyspnea
because there can be many different causes. 49. Nurse Aleli is planning to perform percussion and
Option B: Hyperpnea is breathing more deeply and postural drainage. Which is an important aspect of
sometimes faster than usual. It’s normal during exercise planning the clients’ care?
or exertion. Hyperpnea is breathing deeply, a normal
response to exertion requiring more oxygen. This is A. Percussion and postural drainage should be
when you’re breathing in more air but not necessarily done before lunch.
breathing faster. It can happen during exercise or B. The order should be coughing, percussion,
because of a medical condition that makes it harder for positioning, and then suctioning.
your body to get oxygen, like heart failure or sepsis (a C. A good time to perform percussion and postural
serious overreaction by your immune system). drainage is in the morning after breakfast when the
Option D: Apnea is breathing that stops briefly during client is well rested.
sleep. Oxygen to the brain is decreased. It requires D. Percussion and postural drainage should always be
treatment. Apnea is the medical term used to describe preceded by three minutes of 100% oxygen.
slowed or stopped breathing. Apnea can affect people of
all ages, and the cause depends on the type of apnea Postural drainage results in expectoration of large
one has. Apnea usually occurs while sleeping. For this amounts of mucus. Clients sometimes ingest part of the
reason, it’s often called sleep apnea. secretions. The secretions may also produce an
unpleasant taste in the oral cavity, which could result in
nausea/vomiting. This procedure should be done on an
48. A client with emphysema is prescribed corticosteroid empty stomach to decrease client discomfort.
therapy on a short-term basis for acute bronchitis. The
client asks the nurse how the steroids will help him. The Option B: PD & P involves a combination of techniques,
nurse responded by saying that the corticosteroids will including multiple positions to drain the lungs,
do which of the following? percussion, vibration, deep breathing and coughing.
When the person with CF is in one of the positions, the
A. Promote bronchodilation caregiver can clap on the person’s chest wall. This is
B. Help the client to cough usually done for three to five minutes and is sometimes
C. Prevent respiratory infection followed by vibration over the same area for
D. Decrease inflammation in the airways approximately 15 seconds (or during five exhalations).
The person is then encouraged to cough or huff
Glucocorticoids are prescribed because of their anti- forcefully to get the mucus out of the lungs.
inflammatory effect. Options 1, 2, and 4 are not Option C: Generally, each treatment session can last
achieved with glucocorticoids. Corticosteroids produce for 20 to 40 minutes. PD & P is best done before meals
their effect through multiple pathways. In general, they or one and a half to two hours after eating, to decrease
produce anti-inflammatory and immunosuppressive the chance of vomiting. Early morning and bedtimes are
effects, protein and carbohydrate metabolic effects, usually recommended. The length of PD & P and the
water and electrolyte effects, central nervous system number of times of day it is done may need to be
effects, and blood cell effects. increased if the person is more congested or getting
sick.
Option A: The glucocorticoid receptor is located Option D: When the person with CF is in one of the
intracellularly within the cytoplasm and upon binding positions, the caregiver can clap on the person’s chest
trans-locates rapidly into the nucleus where it affects wall. This is usually done for three to five minutes and is
gene transcription and causes inhibition of gene sometimes followed by vibration over the same area for
approximately 15 seconds (or during five exhalations). area. In general, heat therapy is also recommended
The person is then encouraged to cough or huff prior to exercise for those who have chronic injuries.
forcefully to get the mucus out of the lungs. Heat warms the muscles and helps increase flexibility.
The only time one should ever consider using cold to
treat a chronic injury is after finishing exercising when
50. Nurse Winona teaches a patient how to use an inflammation may reappear. Applying cold at this time
incentive spirometer. What patient outcome will support helps reduce any residual swelling.
the conclusion that the use of the incentives spirometer
was effective? Option A: Both heat and cold relax muscles and thus
minimize muscle spasms. It reduces joint stiffness and
A. Supplemental oxygen use will be reduced. muscle spasm, which makes it useful when muscles are
B. Inspiratory volume will be increased. tight. There is no advantage to using heat over cold.
C. Sputum will be expectorated. When muscles work, chemical byproducts are made that
D. Coughing will be stimulated. need to be eliminated. When exercise is very intense,
there may not be enough blood flow to eliminate all the
An incentive spirometry or provides a visual goal for and chemicals. It is the buildup of chemicals (for example,
measurement of inspiration. It encourages the patient to lactic acid) that cause muscle ache. Because the blood
execute and maintain a sustained inspiration. A supply helps eliminate these chemicals, use heat to help
sustained inspiration opens airways, increases the sore muscles after exercise.
inspiratory volume, and reduces the risk of atelectasis. Option B: Heat does not prevent hemorrhage; heat
Spirometry is one of the most readily available and causes vasodilation, which promotes hemorrhage. Apply
useful tests for pulmonary function. It measures the an ice compress to the injury as soon as possible. This
volume of air exhaled at specific time points during will cool down the tissues, lower their metabolic rate and
complete exhalation by force, which is preceded by a nerve conduction velocity, resulting in vasoconstriction
maximal inhalation. of the surrounding blood vessels and reduced
inflammation.
Option A: Patients who use an incentive spirometer Option D: Both heat and cold can reduce discomfort.
may or may not be receiving oxygen. All patients must Cold reduces discomfort by numbing the area, slowing
be informed that they must abstain from smoking, the transmission of pain impulses, and increasing the
physical exercise in the hours before the procedure. Any pain threshold. Heat reduces the discomfort by relaxing
bronchodilator therapy must also be stopped the muscles. When an injury or inflammation, such as
beforehand. tendonitis or bursitis occurs, tissues are damaged. Cold
Option C: Although sputum may be expectorated after numbs the affected area, which can reduce pain and
the use of an incentive spirometer, this is not the primary tenderness. Cold can also reduce swelling and
reason for its use. Recent evidence also supports the inflammation.
use of spirometry in non thoracic surgeries. A recent
retrospective observational study found that lower
preoperative spirometry FVC may predict postoperative 52. A practitioner orders chest physiotherapy with
pulmonary complications in high-risk patients percussion and vibration for a newly admitted patient.
undergoing abdominal surgery. Which information obtained by the nurse during the
Option D: Although the deep breathing associated with health history should alert the nurse to question the
the use of an incentive barometer may stimulate practitioner’s order?
coughing, this is not the primary reason for its use.
Complete spirometry exams will identify FEV1, forced A. Emphysema
vital capacity (FVC), vital capacity (VC), residual lung B. Osteoporosis
volume (RV), maximum voluntary minute ventilation C. Cystic fibrosis
(MMV), and total lung capacity (TLC). One parametric D. Chronic bronchitis
that is highly indicative of postoperative complications is
predicted postoperative FEV 1(ppo FEV 1). Predicted Implementing the practitioner’s order may compromise
postoperative FEV1 <30% are at a higher risk of patient safety because percussion and vibration in the
postoperative pulmonary complications after thoracic presence of osteoporosis may cause fractures.
surgery. Osteoporosis is an abnormal loss of bone mass and
strength. Chest physiotherapy is a group of physical
techniques that improve lung function and help you
51. Nurse AJ is applying a warm compress. What should breathe better. Chest PT, or CPT expands the lungs,
the nurse explain to the patient is the primary reason strengthens breathing muscles, and loosens and
why heat is used instead of cold? improves drainage of thick lung secretions.

A. Minimizes muscle spasms Option A: These are appropriate interventions for a

B. Prevents hemorrhage patient with emphysema. Emphysema is a chronic
C. Increases circulation pulmonary disease characterized by an abnormal
D. Reduces discomfort increase in the size of air spaces distal to the terminal
bronchioles with destructive changes in their walls.
Heat increases the skin surface temperature, promoting Chest percussion and vibration to help loosen lung
vasodilation, which increases blood flow to the area. secretions. Some patients wear a special CPT vest
Cold has the opposite effect: it promotes hooked up to a machine. The machine makes the vest
vasoconstriction, which decreases blood flow to the vibrate at a high frequency to break up the secretions.
Option C: These are appropriate interventions for a A. Apply sharp for thrusts over the patient's xiphoid
patient with cystic fibrosis causes widespread process.
dysfunction of the exocrine glands. It is characterized by B. Determine if the patient can make any verbal
thick, tenacious secretions in the respiratory system that sounds.
block the bronchioles, creating breathing difficulties. C. Hit the middle of the patients back firmly.
Chest PT helps treat such diseases as cystic fibrosis D. Sweep the patient's mouth with a finger.
and COPD (chronic obstructive pulmonary disease). It
also keeps the lungs clear to prevent pneumonia after When a person is choking on food, the first intervention
surgery and during periods of immobility. is to determine if the person can speak because the next
Option D: These are appropriate interventions for a intervention will depend on if it is partial or total airway
patient with chronic bronchitis. Bronchitis is an obstruction. With a partial airway obstruction, the person
inflammation of the mucous membranes of the bronchial will be able to make sounds because some air can pass
airways. The doctor may recommend chest PT to help from the lungs through the vocal cords. In this situation
loosen and cough up thick or excessive lung secretions the person’s own efforts open parentheses gagging and
from such conditions as lung infections, which include coughing) should be allowed to clear the airway. With a
pneumonia, acute bronchitis, and lung abscess. total airway obstruction, the person will not be able to
make a sound because the airway is blocked and the
nurse should immediately initiate the abdominal thrust
53. Nurse Sue teaches a patient about pursed lip maneuver (Heimlich maneuver).
breathing. The nurse identifies that the teaching is
affected when the patient says its purpose is to: Option A: Thrusts to the xiphoid process may cause a
fracture that may result in a pneumothorax. The foreign
A. Precipitate coughing body lodged in the larynx or trachea is most dangerous
B. Help maintain open airways as this causes complete airway obstruction.
C. Decrease intrathoracic pressure Alternatively, foreign bodies such as small beads or
D. Facilitate expectoration of mucus small pieces of food may pass below the vocal cords
and become lodged at the carina or within a mainstem
Pursed-lip breathing involves deep inspiration and bronchus. In adults, due to differences in right versus left
prolonged expiration against slightly closed lips. The pulmonary anatomy, foreign bodies are more commonly
pursed lips create a resistance to the air flowing out of retrieved from the right main bronchus. However,
the lungs, which prolongs exhalation and maintains children will have equal likelihood in either bronchus,
positive airway pressure, thereby maintaining an open due to equal growth until the age of 16.
airway and preventing airway collapse. Pursed lip Option C: All adults can and should receive the
breathing is beneficial for people with chronic lung Heimlich maneuver while they are conscious. If the
disease. It can help strengthen the lungs and make Heimlich cannot be performed due to body habitus or
them more efficient. pregnancy, the American Heart Association
recommends a supine patient with force again applied
Option A: Deep breathing and huff coughing, not just above the umbilicus in a cephalad posterior vector.
pursed-lip breathing, stimulate effective coughing. Deep If the adult loses consciousness, it is imperative to check
breathing prevents air from getting trapped in the lungs, for a pulse and begin cardiopulmonary resuscitation if a
which can cause the client to feel short of breath. As a pulse is not detected. Advanced airway techniques are
result, the client can breathe in a more fresh air. now indicated, and you may be able to visualize the
Option C: Pursed lip breathing increases, not foreign body under direct laryngoscopy.
decreased intrathoracic pressure. Pursed lip breathing is Option D: Never sweep a choking patient’s mouth with
a simple technique for slowing down a person’s a finger. It might further dislodge the food. The
breathing and getting more air into their lungs. With commonly known abdominal thrust maneuver, known as
regular practice, it can help strengthen the lungs and the Heimlich maneuver, is performed by a bystander on
make them work more efficiently. The technique a person who appears to be choking. The bystander
involves breathing in through the nose and breathing out stands behind the subject and wraps his/her arms
slowly through the mouth. around the upper abdominal region, about two inches
Option D: The huff coughing stimulates the natural above the belly button. Making a fist with one hand and
cough reflex and is effective for clearing the central wrapping the other hand tightly over the fist and
airways of sputum. Saying the word huff with short delivering five sharp midline thrusts inward and upward.
forceful exhalations keeps the glottis open, mobilizes
sputum, and stimulates a cough. When one has COPD,
mucus can build up more easily in the lungs. The huff 55. Nurse Stephanie is assessing a client who has an
cough is a breathing exercise designed to help one acute respiratory infection that puts her at risk for
cough up mucus effectively without making one feel too hypoxemia. Which of the following findings are early
tired. A huff cough should be less tiring than a traditional indications that should alert the nurse that the client is
cough, and it can keep one from feeling worn out when developing hypoxemia? Select all that apply.
coughing up mucus.
A. Restlessness
B. Tachypnea
54. What should Nurse Mavie do first if a patient is C. Bradycardia
choking on food? D. Confusion
E. Cyanosis
Restlessness, tachypnea, and pallor are early oxygenation status, there is a higher priority given the
manifestations of hypoxemia, along with tachycardia, nature of the client’s distress.
elevated blood pressure, use of accessory muscles, Option C: The client may need suction or expectoration,
nasal flaring, tracheal tugging, and adventitious lung as pulmonary secretions may be the cause of his
sounds. Bradycardia and confusion are late difficulty breathing. However, there is a higher priority
manifestations of hypoxemia, along with stupor, cyanotic given the nature of the client’s distress.
skin and mucous membranes, bradypnea, hypotension, Option D: It is important to check the client’s
and cardiac dysrhythmias. Hypoxemia is defined as a oxygenation status, and in many nursing situations,
decrease in the partial pressure of oxygen in the blood assessment precedes action, but there is a higher
whereas hypoxia is defined by reduced level of tissue priority given the nature of the clients’ distress.
oxygenation. It can be due to either defective delivery or
defective utilization of oxygen by the tissues.
57. Nurse Aldrin is preparing to perform endotracheal
Option A: When oxygen delivery is severely suctioning for a client. Which of the following are
compromised, organ function will start to deteriorate. appropriate guidelines for the nurse to follow? Select all
Neurologic manifestations include restlessness, that apply.
headache, and confusion with moderate hypoxia. In
severe cases, altered mentation and coma can occur, A. Apply suction while withdrawing the catheter.
and if not corrected quickly may lead to death. B. Perform suctioning on a routine basis, every 2 to 3
Option B: The chronic presentation is usually less hours.
dramatic, with dyspnea on exertion as the most common C. Maintain medical asepsis during suctioning.
complaint. Symptoms of the underlying condition that D. Use a new catheter for each suctioning attempt.
induced the hypoxia can help in narrowing the E. Limit suctioning to 2 to 3 attempts.
differential diagnosis. The physical exam may show
tachypnea and low oxygen saturation. Fever may point Within intensive care units (ICUs), one such common
to infection as the cause of hypoxia. procedure is the suctioning of respiratory secretions in
Option C: Bradycardia is a late manifestation of patients who have been intubated or who have
hypoxemia. Increase in cardiac output with exercise undergone tracheostomy. The traditional goal of
results in accelerated blood flow through alveoli, suctioning is to aid in maintaining airway patency and
reducing the time available for gas exchange. In case of prevent complications related to the retention of
the abnormal pulmonary interstitium, gas exchange time secretions
becomes insufficient, and hypoxemia ensues.
Option D: Both confusion and somnolence may occur in Option A: The nurse should apply suction pressure only
respiratory failure. Myoclonus and seizures may occur while withdrawing the catheter, not while inserting it.
with severe hypoxemia. Polycythemia is a complication One interesting thing to note about ETS is that negative
of long-standing hypoxemia. pressure is created inside of the lungs only while air
Option E: Cyanosis, a bluish color of skin and mucous flows out of the suction catheter. As soon as secretions
membranes, indicates hypoxemia. Visible cyanosis are aspirated into the catheter, the intrapulmonary
typically is present when the concentration of pressure returns to that of the atmospheric level, and
deoxygenated hemoglobin in the capillaries of tissues is lung volume loss stops.
at least 5 g/dL. Option B: The nurse should not suction routinely
because suctioning is not without risk. It can cause
mucosal damage, bleeding, and bronchospasm.
56. Nurse CJ is caring for a client who is having difficulty Although there has been a very limited number of
breathing. The client is lying in bed and is already studies regarding a scheduled frequency of performing
receiving oxygen therapy via nasal cannula. Which of ETS every 1, 3, 4, 6, 8, or even 12 hours, the overall
the following interventions is the nurse’s priority? recommendation is to suction only as indicated (as
needed).
A. Increase the oxygen flow. Option C: Endotracheal suctioning requires surgical
B. Assist the client with Fowler's position. asepsis. The second method of suctioning is the shallow
C. Promote removal of pulmonary secretions. (premeasured) technique, which is also considered
D. Attain a specimen for arterial blood gases. minimally invasive.1-3 With shallow ETS, the catheter is
inserted only to the tip of the ETT, thereby avoiding
The priority action the nurse should take when using the injury to the airway.
airway, breathing, circulation approach to care delivery Option D: The nurse should not reuse the suction
is to relieve the clients’ dyspnea. Fowler’s position catheter unless an in-line suctioning system is in place.
facilitates maximal long expansion and thus optimizing If a suction catheter is too large for the ETT, and/or
breathing. With the client in this position, the nurse can there is too much vacuum pressure, massive atelectasis
better assess and determine the cause of the clients may occur. Therefore, the general recommendation is to
dyspnea. use a suction catheter that has an external diameter less
than 50% of the size of the ETT inner diameter.
Option A: The client may need more oxygen, as Option E: To prevent hypoxemia, the nurse should limit
hypoxemia may be the cause of his difficulty breathing. each section in session to 2 to 3 attempts and allow at
However, administering oxygen and adjusting the least one minute between passes for ventilation and
fraction of inspired oxygen requires the provider’s oxygenation. The reason for this is because there is
prescription after a careful assessment of the clients’ considerable risk with using “routine” suctioning. It has
been suggested by Pedersen et al3 that ETS should be
performed at least every 8 hours to slow the formation of avoids the use of knots, which can come untied or cause
the secretion biofilm within the lumen of the pressure and irritation.
endotracheal tube (ETT). Clifton-Koeppel1 made a good Option E: The nurse should use a commercially
general recommendation that ETS should be performed prepared tracheostomy dressing with a slit in it. Cutting
as infrequently as possible—yet as much as needed. gauze squares can loosen lint or cause fibers the client
could aspirate. Use a commercially prepared
tracheostomy dressing of non-raveling material or open
58. A nurse is caring for a client who has a and refold a 4-in. X 4-in. Gauze dressing into a V shape.
tracheostomy. Which of the following actions should the Avoid using cotton-filled gauze squares or cutting the
nurse take each time he provides tracheostomy care? 4×4 gauze. Cotton lint or gauze fibers can be aspirated
Select all that apply. by the client, potentially creating a tracheal abscess.

A. Apply the oxygen source loosely if the SPO2

increases during the procedure. 59. An elderly nursing home resident has refused to eat
B. Use surgical asepsis to remove and clean the or drink for several days and is admitted to the hospital.
inner cannula. The nurse should expect which assessment finding?
C. Clean the outer surfaces in a circular motion
from the stoma site outward. A. Increase blood pressure
D. Replace the tracheostomy ties with new ties. B. Weak, rapid pulse
E. Cut a slit in gauze squares to place beneath the tube C. Moist mucous membranes
holder. D. Jugular vein distention

A tracheostomy is an opening (made by an incision) All other options are indicated by fluid volume excess. A
through the neck into the trachea (windpipe). A client who has not eaten or drunk anything for several
tracheostomy opens the airway and aids breathing. A days would be experiencing a fluid volume deficit. The
tracheostomy may be required in an emergent setting to primary control of water homeostasis is through
bypass an obstructed airway, or (more commonly) may osmoreceptors in the brain. Dehydration, as perceived
be placed electively to facilitate mechanical ventilation, by these osmoreceptors, stimulates the thirst center in
to wean from a ventilator, or to allow more efficient the hypothalamus, which leads to water consumption.
management of secretions (referred to as pulmonary These osmoreceptors can also cause conservation of
toilet), among other reasons. water by the kidney. When the hypothalamus detects
lower water concentration, it causes the posterior
Option A: The nurse must be prepared to provide pituitary to release antidiuretic hormone (ADH), which
supplemental oxygen in response to any decline in stimulates the kidneys to reabsorb more water.
oxygenation saturation while performing tracheostomy
care. Nurses need to understand all aspects of Option A: Decreased blood pressure, which often
tracheostomy care, including routine and emergency accompanies dehydration triggers renin secretion from
airway management, safe decannulation, weaning and the kidney. Renin converts angiotensin I to angiotensin
safe discharge into the community. The patient’s airway II, which increases aldosterone release from the
requires close monitoring 24 hours a day using a adrenals. Aldosterone increases the absorption of
tracheostomy care chart to record care. sodium and water from the kidney. Using these
Option B: The nurse should use a sterile disposable mechanisms, the body regulates body volume and
tracheostomy cleaning kit or sterile supplies and sodium and water concentration.
maintain surgical asepsis throughout this part of the Option C: Some of the most common presenting
procedure. The NTSP (2013) recommends that all symptoms of dehydration include but are not limited to
patients with a tracheostomy have a bed-head label with fatigue, thirst, dry skin and lips, dark urine or decreased
information regarding their tube and airway, including urine output, headaches, muscle cramps,
whether it is surgical or percutaneous, the tube type, lightheadedness, dizziness, syncope, orthostatic
size and suction-catheter size, patency of the upper hypotension, and palpitations. The physical examination
airway and whether the tracheostomy is temporary, could show dry mucosa, skin tenting, delayed capillary
permanent or involves a laryngectomy (removal of the refill, or cracked lips.
larynx). Option D: A 2015 Cochrane review evaluated predictors
Option C: This action helps move mucus and of dehydration in the elderly. Historical and physical
contaminated material away from the stoma for easy findings tested were dry axilla, mucous membranes,
removal. The stoma site should be checked at least tongue, increased capillary refill time, poor skin turgor,
once a day, or more frequently if required, and this sunken eyes, orthostatic blood pressure drop, dizziness,
requires two nurses: one to hold the tube and one to thirst, urine color, weakness, blue lips, altered
clean the stoma site. The site should be cleaned using a mentation, tiredness, and appetite. Of all these factors
tracheostomy wipe or with 0.9% sodium chloride only fatigue and missed drinks between meals predicted
solution, and dried thoroughly. the diagnosis of dehydration.
Option D: To help keep the skin clean and dry, the
nurse should replace the tracheostomy ties if they are
wet or soiled. There is a risk of two dislodgements 60. A man brings his elderly wife to the emergency
replacing the ties, so he should not replace them department. He states that she has been vomiting and
routinely. Leaving the old ties in place while securing the has had diarrhea for the past two days. She appears
clean ties prevents inadvertent dislodging of the lethargic and is complaining of leg cramps. What should
tracheostomy tube. Securing tapes in this manner the nurse do first?
 uncommon for practitioners to have difficulty
A. Start an IV. understanding the abbreviations used in their hospitals.
B. Review the results of serum electrolytes. Option D: To prevent misunderstandings and potential
C. Offer the woman foods that are high in sodium and risks to patient safety, requires hospitals to establish
potassium content. lists for approved and do-not-use abbreviations and
D. Administer an antiemetic. monitor for appropriate abbreviation use. There are
resources for identifying abbreviations for the do-not-use
Further assessment is needed to determine appropriate list, such as the Institute for Safe Medication Practices
action. While the nurse may perform some of the (ISMP), which publishes a list of dangerous
interventions in options one, three, and four, abbreviations not to be used due to frequent
assessment is needed initially. Electrolyte abnormalities misinterpretation and associated medication errors.
may be addressed on an individual level, although often
these are caused by an overall fluid volume depletion
which, when corrected, will also cause electrolytes to 62. One (1) tsp is equal to how many drops?
normalize. Both saline and lactated Ringer’s solutions
appear to be effective for the treatment of dehydration A. 15
due to viral gastroenteritis. B. 60
C. 10
Option A: The most important goal of treatment is to D. 30
maintain hydration status and effectively counter fluid
and electrolyte losses. Fluid therapy is a fundamental One teaspoon (tsp) is equal to 60 drops (gtts). When the
part of treatment. Intravenous fluids may be nurse has an order for an IV infusion, it is her
administered to those individuals who appear responsibility to make sure the fluid will infuse at the
dehydrated or to those unable to tolerate oral fluids. prescribed rate. IV fluids may be infused by gravity using
Option C: No specific nutritional recommendations are a manual roller clamp or dial-a-flow, or infused using an
universal for patients with viral gastroenteritis. A diet of infusion pump. Regardless of the method, it is important
banana, rice, apples, tea, and toast is often advised, but to know how to calculate the correct IV flow rate.
several studies have failed to show any significant
outcome difference when compared to regular diets. Option A: When calculating the flow rate, determine
Option D: Antiemetic medications such as ondansetron which IV tubing will be used, microdrip or macrodrip, so
or metoclopramide may be used to assist with the nurse can use the proper drop factor in her
controlling nausea and vomiting symptoms. Patients calculations. The drop factor is the number of drops in
demonstrating severe dehydration or intractable one mL of solution, and is printed on the IV tubing
vomiting may require hospital admission for continued package. Macrodrip and microdrip refers to the diameter
intravenous fluids and careful monitoring of electrolyte of the needle where the drop enters the drip chamber.
status. Option C: Macrodrip tubing delivers 10 to 20 gtts/mL
and is used to infuse large volumes or to infuse fluids
quickly. Microdrip tubing delivers 60 gtts/mL and is used
61. Which of the following is the appropriate meaning of for small or very precise amounts of fluid, as with
CBR? neonates or pediatric patients.
Option D: To calculate the drops per minute, the drop
A. Cardiac Board Room factor is needed. The formula for calculating the IV flow
B. Complete Bathroom rate (drip rate) is… total volume (in mL) divided by time
C. Complete Bed Rest (in min), multiplied by the drop factor (in gtts/mL), which
D. Complete Board Room equals the IV flow rate in gtts/min.

CBR means complete bed rest. For more abbreviations,

please see this post. Standardization and uniform use of 63. 20 cc is equal to how many ml?
codes, symbols, and abbreviations can improve
communication and understanding between health care A. 2
practitioners, leading to safer and more effective care for B. 20
patients. C. 2000
D. 20000
Option A: When developing lists, hospitals need to
ensure that abbreviations on the approved list are not One cubic centimeter is equal to one milliliter. When
also on the do-not-use list, and vice versa. In addition, clinicians are prepared and know the key conversion
abbreviations can have only one meaning within the factors, they will be less anxious about the calculation
entire organization—for example, the abbreviation involved. This is vital to accuracy, regardless of which
NKDA could mean “no known drug allergies,” or it could formula or method employed.
mean “nonketotic diabetic acidosis,” but it cannot have
both meanings in an organization. Option A: Drug calculations require the use of
Option B: Appropriate use of abbreviations is conversion factors, for example, when converting from
particularly important. Numerous studies have focused pounds to kilograms or liters to milliliters. Simplistic in
on health care practitioners’ understanding and design, this method allows clinicians to work with
interpretation of abbreviations in medical documents, various units of measurement, converting factors to find
such as medical records, discharge summaries, and the answer. These methods are useful in checking the
medication orders. Findings indicate that it is not
accuracy of the other methods of calculation, thus acting C. State the client’s name aloud and have the client
as a double or triple check. repeat it.
Option C: Units of measurement must match, for D. Check the room number.
example, milliliters and milliliters, or one needs to
convert to like units of measurement. In the example The identification band is the safest way to know the
above, the ordered dose was in milligrams, and the have identity of a patient whether he is conscious or
dose was in milligrams, both of which cancel out leaving unconscious. Nurses have a unique role and
milliliters (answer called for milliliters), so no further responsibility in medication administration, in that they
conversion is required. are frequently the final person to check to see that the
Option D: All members of the interprofessional team are medication is correctly prescribed and dispensed before
responsible for dose calculations. Physicians, nurses, administration.
and pharmacists all must be conversant in the desired
overall formula. This technique is invaluable in properly Option A: Ask the client his name only after you have
treating patients. checked his ID band. Right patient’ – ascertaining that a
patient being treated is, in fact, the correct recipient for
whom medication was prescribed. This is best practiced
64. 1 cup is equal to how many ounces? by nurses directly asking a patient to provide his or her
full name aloud, checking medical wristbands if
A. 8 appropriate for matching name and ID number as on a
B. 80 chart.
C. 800 Option C: It is advisable not to address patients by first
D. 8000 name or surname alone, in the event, there are two or
more patients with identical or similar names in a unit.
One cup is equal to 8 ounces. Weight conversion is also Depending on the unit that a patient may be in, some
utilized daily in health care. There are two systems patients, such as psychiatric patients, may not wear
calculating weight used in all healthcare settings for wristbands or may have altered mentation to the point
health management, such as medication dosing per where they are unable to identify themselves correctly.
patient body weight. First, the metric system is in In these instances, nurses are advised to confirm a
common use in health care in the US. It is also the only patient’s identity through alternative means with
system universally used in many countries on all appropriate due diligence.
continents of the globe. It has the advantage of a Option D: The medical literature states that the value of
decimal system in increments or the power of tenths. nurses’ critical thinking, the role of patient advocacy, and
Second, the US weight system customarily uses the clinical judgment are not accounted for by the five rights
ounce or pound. It derives from the British colonial era. framework that is commonly observed in modern
This non-metric system is still being used nowadays practice to deliver patient-centered care. Research has
among laypersons in the US for products sold to the shown a clear benefit in the value of nursing experience
public. as it relates to decision-making capability; however, it
states that further studies are necessary to achieve an
Option B: The metric system is essential in all health improved understanding of how nurses apply intuition,
care settings. Patients are weighed at each clinical the context of the situation, and interpretation.
encounter. Scales used in the US have double marking
indicators: metric and non-metric markings. Metric
weight values are used in medication calculation, 66. The nurse prepares to administer buccal medication.
radiation dosing, and weight compliance in equipment The medicine should be placed in what area?
use, such as the maximum weight of a CAT-SCAN unit
or a surgical table that may hold a person. A. On the client’s skin.
Option C: Nowadays, all medications are based on B. Between the client’s cheeks and gums.
weight for dose calculations for all populations but very C. Under the client’s tongue.
specifically in children and infants. Adults have their D. On the client’s conjunctiva.
weight recorded mainly by their doctors at each physical
patient-clinician encounter. Commonly, most adults Buccal administration involves placing a drug between
monitor their weight for weight management. Clinicians the gums and cheek, where it also dissolves and is
record it in the electronic health records in both absorbed into the blood. Because the medication
kilograms and pounds. absorbs quickly, these types of administration can be
Option D: Commonly in healthcare and medical important during emergencies when you need the drug
practices, the metric system is used for weighing mass. to work right away, such as during a heart attack.
In the metric system, there are increments at the power
of the tenth for calculations. This weight conversion is Option A: An advantage of a transdermal drug delivery
used daily among scientists and health care providers. route over other types of medication delivery such as
oral, topical, intravenous, intramuscular, etc. is that the
patch provides a controlled release of the medication
65. The nurse must verify the client’s identity before into the patient, usually through either a porous
administration of medication. Which of the following is membrane covering a reservoir of medication or through
the safest way to identify the client? body heat melting thin layers of medication embedded in
the adhesive.
A. Ask the client his name. Option C: Sublingual administration involves placing a
B. Check the client’s identification band. drug under the tongue to dissolve and absorb into the
blood through the tissue there. These drugs do not go C. Check the availability of a liquid preparation.
through the digestive system, so they aren’t metabolized D. Crush the capsule and place it under the tongue.
through the liver. This means you may be able to take a .
lower dose and still get the same results.
Option D: The three primary methods of delivery of The nurse should check first if the medication is
ocular medications to the eye are topical, local ocular available in liquid form before doing Choice A. The
(ie, subconjunctival, intravitreal, retrobulbar, swallowing of capsules can be particularly difficult. This
intracameral), and systemic. The most appropriate is because capsules are lighter than water and float due
method of administration depends on the area of the eye to air trapped inside the gelatine shell. In comparison,
to be medicated. The conjunctiva, cornea, anterior tablets are heavier than water and do not float.
chamber, and iris usually respond well to topical
therapy. The eyelids can be treated with topical therapy Option A: The physical properties of capsules
but more frequently require systemic therapy. The predispose them to floating in the mouth when taken
posterior segment always requires systemic therapy, with water. As a result, the swallowing of capsules can
because most topical medications do not penetrate to be problematic. In patients who experience such
the posterior segment. Retrobulbar and orbital tissues difficulty, it is suggested that they try leaning forward
are treated systemically. when swallowing, as this has been found to assist. It
may be necessary to reassure patients about this
technique as they may initially find it unnatural to
67. The nurse administers a cleansing enema. The execute.
common position for this procedure is? Option B: Some tablets, pills and capsules don’t work
properly or may be harmful if they’re crushed or opened.
A. Sims left lateral Most capsules are intended to be swallowed whole so
B. Dorsal Recumbent patients should be encouraged to trial the ‘lean-forward’
C. Supine technique. If swallowing difficulties remain other options,
D. Prone such as a liquid or tablet form of the medicine, can be
considered.
This position provides comfort to the patient and easy Option D: Placing it under the tongue is not the
access to the natural curvature of the rectum. Enemas intended way of administering an oral medication.
are rectal injections of fluid intended to cleanse or Crushing the medication may alter the medicine’s
stimulate the emptying of the bowel. Enemas may also effects. You shouldn’t chew, crush or break tablets or
be prescribed to flush out the colon before certain pills, or open and empty powder out of capsules unless
diagnostic tests or surgeries. The bowel needs to be your GP or another healthcare professional has told you
empty before these procedures to reduce infection risk to do so. Some tablets, pills, and capsules don’t work
and prevent stool from getting in the way. properly or may be harmful if they’re crushed or opened.

Option B: Position the patient on the left side, lying with

the knees drawn to the abdomen. This eases the 69. Which of the following is the appropriate route of
passage and flow of fluid into the rectum. Gravity and administration for insulin?
the anatomical structure of the sigmoid colon also
suggest that this will aid enema distribution and A. Intramuscular
retention. Dorsal recumbent is a position in which the B. Intradermal
patient lies on the back with the lower extremities C. Subcutaneous
moderately flexed and rotated outward. It is employed in D. Intravenous
the application of obstetrical forceps, repair of lesions
following parturition, vaginal examination, and bimanual The subcutaneous tissue of the abdomen is preferred
palpation. because the absorption of the insulin is more consistent
Option C: The supine position means lying horizontally from this location than subcutaneous tissues in other
with the face and torso facing up, as opposed to the locations. Insulin may be injected into the subcutaneous
prone position, which is face down. When used in tissue of the upper arm and the anterior and lateral
surgical procedures, it allows access to the peritoneal, aspects of the thigh, buttocks, and abdomen (with the
thoracic, and pericardial regions; as well as the head, exception of a circle with a 2-inch radius around the
neck, and extremities. navel).
Option D: Prone position is a body position in which the
person lies flat with the chest down and the backup. In Option A: Intramuscular injection is not recommended
anatomical terms of location, the dorsal side is up, and for routine injections. Rotation of the injection site is
the ventral side is down. The supine position is the 180° important to prevent lipohypertrophy or lipoatrophy.
contrast. Rotating within one area is recommended (e.g., rotating
injections systematically within the abdomen) rather than
rotating to a different area with each injection. This
68. A client complains of difficulty swallowing when the practice may decrease variability in absorption from day
nurse tries to administer capsule medication. Which of to day.
the following measures should the nurse do? Option B: Site selection should take into consideration
the variable absorption between sites. The abdomen
A. Dissolve the capsule in a glass of water. has the fastest rate of absorption, followed by the arms,
B. Break the capsule and give the content with thighs, and buttocks. Exercise increases the rate of
applesauce.
absorption from injection sites, probably by increasing near the edge of the bed so that he is as near the
blood flow to the skin and perhaps also by local actions. operator as possible. If the supine position is used and
Option D: Administration of mixtures of rapid- or short- the patient is a woman, a pillow under the abdomen
and intermediate- or long-acting insulins will produce a removes pressure from the breasts and favors
more normal glycemia in some patients than the use of relaxation. Apply to back rubbing lotion or talcum
single insulin. The formulations and particle size powder to reduce friction. In rubbing the back use firm
distributions of insulin products vary. On mixing, long strokes and kneading motions. The amount of
physicochemical changes in the mixture may occur pressure to exert depends upon the patient’s condition.
(either immediately or over time). As a result, the Begin from the neck and shoulders then proceed over
physiological response to the insulin mixture may differ the entire back.
from that of the injection of the insulins separately. Option C: Massage with both hands working with a
strong stroke. In upward then in downward motions.
Give particular attention to pressure areas in rubbing
70. The nurse is ordered to administer ampicillin capsule (Alcohol 25%) to 50% is generally used for its refreshing
TID p.o. The nurse should give the medication by which effect, but rubbing lotion may be used. Powder again the
frequency? area at the completion of the rubbing process which
should consume from 3-5 minutes.
A. Three times a day orally Option D: Effleurage (stroking) is a long sweeping
B. Three times a day after meals movement with the palm of hand conforming to the
C. Two times a day by mouth contour of the surface-treated, over a small surface (on
D. Two times a day before meals the neck) the thumb and fingers are used. Strokes
should be slow, rhythmical, and gentle with pressure
TID is the Latin for “ter in die” which means three times constant and in the direction of the venous stream.
a day. P.O. means per orem or through mouth. The Kneading is performed with the ulnar side palm resting
“time” of administration of medication is valuable on the surface and the fingers, and thumb grasping the
information to consider during patient counselling and is skin and subcutaneous tissues which move with the
a typical query by patients especially when filling a hand of the operator.
prescription for the first time.

Option B: The timing of doses isn’t the only question 72. It refers to the preparation of the bed with a new set
people may have when it comes to deciphering of linens
prescriptions or oral communication from the doctor.
Other abbreviations include the number of refills allowed A. Bed bath
and whether one is receiving a brand name or generic B. Bed making
drug. Medical errors are a significant cause of death in C. Bed shampoo
the United States. Fortunately, most of these errors are D. Bed lining
preventable when patients are active advocates for their
health and ask plenty of questions. Bed making is one of the important nursing techniques
Option C: Two times a day by mouth is BID P.O. Seen to prepare various types of bed for patients or clients to
on a prescription, b.i.d. means twice (two times) a day. It guarantee comfort and beneficial position for a specific
is an abbreviation for “bis in die” which in Latin means condition. The bed is particularly important for patients
twice a day. The abbreviation b.i.d. is sometimes written who are sick. The nurse plays an inevitable role to
without a period either in lower-case letters as “bid” or in ensure comfort and cleanliness for ill patients. It should
capital letters as “BID”. be adaptable to various positions as per patient’s needs
Option D: However it is written, it is one of a number of because they spend a varying amount of the day in bed.
hallowed abbreviations of Latin terms that have been
traditionally used in prescriptions to specify the Option A: Bed bathing is not as effective as showering
frequency with which medicines should be taken. or bathing and should only be undertaken when there is
no alternative (Dougherty and Lister, 2015). If a bed
bath is required, it is important to offer patients the
71. Back Care is best described as: opportunity to participate in their own care, which helps
to maintain their independence, self-esteem and dignity.
A. Caring for the back by means of massage. Option C: The condition of their hair and how it is styled
B. Washing of the back. is an important part of patients’ identity and wellbeing,
C. Application of cold compress at the back. so assisting them with hair care is a fundamental aspect
D. Application of hot compress at the back. of nursing care
Option D: The purpose of a well-made hospital bed, as
Back care or massage is usually given in conjunction well as an appropriately chosen mattress, is to provide a
with the activities of bathing the client. It can also be safe, comfortable place for the patient, where
done on other occasions when a client seems to have a repositioning is more easily achieved, and pressure
risk of developing skin irritation due to bed rest. The goal ulcers are prevented.
when performing this procedure is to enhance
relaxation, reduce muscle tension and stimulate
circulation. 73. Which of the following is the most important purpose
of handwashing?
Option B: Help the patient to turn on his abdomen or on
his side with his back toward the nurse and his body
A. To promote hand circulation.
B. To prevent the transfer of microorganisms. Option B: There is now a common understanding that
C. To avoid touching the client with a dirty hand. linens, once in use, are usually contaminated and could
D. To provide comfort. be harboring microorganisms such as MRSA and VRE.
Further, the Centers for Disease Control and Prevention
Hand washing is the single most effective infection (CDC) cautions that healthcare professionals should
control measure. Handwashing practices in the patient handle contaminated textiles and fabrics with minimum
care setting began in the early 19th century. The agitation to avoid contamination of air, surfaces, and
practice evolved over the years with evidential proof of persons. Even one of the leading nursing textbooks,
its vast importance and coupled with other hand- Fundamentals of Nursing, Soiled linen is never shaken
hygienic practices, decreased pathogens responsible for in the air because shaking can disseminate secretions
nosocomial or hospital-acquired infections (HAI). and excretions and the microorganisms they contain.
This text also states linens that have been soiled with
Option A: According to the Centers for Disease Control excretions and secretions harbor microorganisms that
and Prevention (CDC), hand hygiene is the single most can be transmitted to others.
important practice in the reduction of the transmission of Option C: Healthcare laundry protocols have long relied
infection in the healthcare setting Transient on chlorine-based sanitizers to kill bacteria in bed linens
microorganisms are often acquired by healthcare and other fabrics. While chlorine is known as one of the
workers through direct, close contact with patients or best antimicrobial agents in the world, its power has
contaminated inanimate objects or environmental been limited because it evaporates from untreated fabric
surfaces. Transient flora colonizes the superficial skin soon after laundering. But with this new patented
layers. It can be removed by routine hand washing more technology in HaloShield ® linens, the chlorine keeps
easily than resident flora. These organisms vary in killing bacteria right up until the next laundering.
number depending upon body location. Healthcare- Option D: The environment in which linens are used in
associated infections are a result of these transient healthcare is often ideal for the proliferation and spread
organisms. of bacteria and viruses. Often the patient, in a weakened
Option C: Contaminated hands of healthcare providers or compromised state, is lying on a sheet. That sheet
are a primary source of pathogenic spread. Proper hand under the patient’s body is warm, dark, and sometimes
hygiene decreases the proliferation of microorganisms, damp. Most would agree that those conditions are
thus reducing infection risk and overall healthcare costs, considered ideal for bacteria and viruses to thrive.
length of stays, and ultimately, reimbursement.
According to the CDC, hand hygiene encompasses the
cleansing of your hands with soap and water, antiseptic 75. The most important purpose of cleansing bed bath
hand washes, antiseptic hand rubs such as alcohol- is:
based hand sanitizers, foams or gels, or surgical hand
antisepsis. A. To cleanse, refresh and give comfort to the client
Option D: Indications for handwashing include when who must remain in bed.
hands are visibly soiled, contaminated with blood or B. To expose the necessary parts of the body.
other bodily fluids, before eating, and after restroom use. C. To develop skills in bed bath.
Hands should be washed if there was potential exposure D. To check the body temperature of the client in bed.
to Clostridium difficile, Norovirus, or Bacillus anthracis.
Alcohol-based hand sanitizers are the recommended The nurse provides a bed bath for patients who must
product for hand hygiene when hands are not visibly remain in bed and depend on someone else for their
soiled. Apply alcohol-based products per manufacturer care. It is an important part of the patient’s daily care.
guidelines on dispensing of the product. Typically, 3 mL Not only does it remove sweat, oil, and micro-organisms
to 5 mL in the palm, rubbing vigorously, ensuring all from the patient’s skin, but it also stimulates circulation
surfaces on both hands get covered, about 20 seconds and promotes a feeling of self-worth by improving the
is required for all surfaces to dry completely. patient’s appearance. For patients who are on bedrest,
bathing can also be a time for socialization.

74. What should be done in order to prevent Option B: During bed bath, the patient is always given
contaminating the environment in bed making? privacy so as not to expose their intimate parts of the
body. Some patients cannot safely leave their beds to
A. Avoid fanning soiled linens bathe. For these people, daily bed baths can help keep
B. Strip all linens at the same time their skin healthy, control odor, and increase comfort. If
C. Finished both sides at the time moving the patient causes pain, plan to give the patient
D. Embrace soiled linen a bed bath after the person has received pain medicine
and it has taken effect.
Fanning soiled linens would scatter the lodged Option C: The nurse may develop her skills in bed bath,
microorganisms and dead skin cells on the linens. but it is not the main purpose. A bed bath is a good time
Healthcare linens are known to harbor a number of to inspect a patient’s skin for redness and sores. Pay
microorganisms. Most notably, there is an increased special attention to skin folds and bony areas when
concern that methicillin-resistant Staphylococcus aureus checking. Encourage the patient to be involved as
(MRSA)and vancomycin-resistant Enterococcus (VRE) possible in bathing themselves.
can survive for days on linens. There is further concern Option D: A bed bath may give a relaxation effect on
that these contaminated linens then become a potential the patient. It may also stimulate blood circulation to the
source of cross-contamination. skin, respiration, and elimination; maintain joint mobility,
and improve the patient’s self-image and emotional and
mental well-being. It provides the nurse with an
opportunity for health teaching and assessment; gives
the patient psychological support, and the process of
building rapport may begin during the initial bath.