- After teaching a client who has stress incontinence, the nurse assesses the client’s
understanding. Which statement made by the client indicates a need for additional teaching?
a. “I will limit my total intake of fluids.”
b. “I must avoid drinking alcoholic beverages.”
c. “I must avoid drinking caffeinated beverages.”
d. “I shall try to lose about 10% of my body weight.”
Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence.
Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages
are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.
- A nurse cares for adult clients who experience urge incontinence. For which client should the
nurse plan a habit training program?
a. A 78-year-old female who is confused
b. A 65-year-old male with diabetes mellitus
c. A 52-year-old female with kidney failure
d. A 47-year-old male with arthritis
For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware,
and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going
to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from another
type of bladder training.
- After delegating care to anunlicensed assistive personnel (UAP) for a client who is prescribed
habit training to manage incontinence, a nurse evaluates the UAP’s understanding. Which action
indicates the UAP needs additional teaching?
a. Toileting the client after breakfast
b. Changing the client’s incontinence brief when wet
c. Encouraging the client to drink fluids
d. Recording the client’s incontinence episodes
Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse
should re-educate the UAP on the technique of habit training. The UAP should continue to toilet
the client after meals, encourage the client to drink fluids, and record incontinent episodes.
- A nurse plans care for a client with overflow incontinence. Which intervention should the
nurse include in this client’s plan of care to assist with elimination?
a. Stroke the medial aspect of the thigh.
b. Use intermittent catheterization.
c. Provide digital anal stimulation.
d. Use the Valsalva maneuver.
In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressures, such as that
achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate
voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to
be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be
implemented when other interventions are not successful.
- After teaching a client with a history of renal calculi, the nurse assesses the client’s
understanding. Which statement made by the client indicates a correct understanding of the
a. “I should drink at least 3 liters of fluid every day.”
b. “I will eliminate all dairy or sources of calcium from my diet.”
c. “Aspirin and aspirin-containing products can lead to stones.”
d. “The doctor can give me antibiotics at the first sign of a stone.”
Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium
causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the
calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the
urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not
decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics
neither prevent nor treat a stone.
- A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi.
The nurse notes an ecchymosis area on the client’s right lower back. Which action should the nurse take?
a. Administer fresh-frozen plasma.
b. Apply an ice pack to the site.
c. Place the client in the prone position.
d. Obtain serum coagulation test results.
ANS: BThe shock waves from lithotripsy can cause bleeding into the tissues through which the
waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although
coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders,
ecchymosis after this procedure is not unusual and does not warrant a higher level of
intervention. Changing the client’s position will not decrease bleeding.
- A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal
conduit. Which assessment finding should alert the nurse to urgently contact the health care provider?
a. The ileostomy is draining blood-tinged urine.
b. There is serous sanguineous drainage present on the surgical dressing.
c. The ileostomy stoma is pale and cyanotic in appearance.
d. Oxygen saturations are 92% on room air.
A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to
prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this
type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.
- A nurse teaches a client with functional urinary incontinence. Which statement should the
nurse include in this client’s teaching?
a. “You must clean around your catheter daily with soap and water.”
b. “Wash the vaginal weights with a 10% bleach solution after each use.”
c. “Operations to repair your bladder are available, and you can consider these.”
d. “Buy slacks with elastic waistbands that are easy to pull down.”
Functional urinary incontinence occurs as the result of problems not related to the client’s bladder, such as
trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or
her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the
toilet in time to void. The other instructions do not relate to functional urinary incontinence.
- An emergency department nurse assesses a client with a history of urinary incontinence who
presents with extreme dry mouth, constipation, and an inability to void. Which question should
the nurse ask first?
a. “Are you drinking plenty of water?”
b. “What medications are you taking?”
c. “Have you tried laxatives or enemas?”
d. “Has this type of thing ever happened before?”
Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine).
Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess
the client’s medication list to determine whether the client is taking an anticholinergic medication. If he or she
is taking anticholinergics, the nurse should further assess the client’s manifestations to determine if they are
related to a simple side effect or an overdose. The other questions are not as helpful to understanding the
- A nurse plans care for clients with urinary incontinence. Which client is correctly paired with
the appropriate intervention?
a. A 29-year-old client after a difficult vaginal delivery – Habit training
b. A 58-year-old postmenopausal client who is not taking estrogen therapy – Electrical stimulation
c. A 64-year-old female with Alzheimer’s-type senile dementia – Bladder training
d. A 77-year-old female who has difficulty ambulating – Exercise therapy
ANS: BExercise therapy and electrical stimulation are used for clients with stress incontinence related to
childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall
strength; it does not improve ambulation. Physical therapy and a bedside commode would be
appropriate interventions for the client who has difficulty ambulating. Habit training is the type
of bladder training that will be most effective with cognitively impaired clients. Bladder training
can be used only with a client who is alert, aware, and able to resist the urge to urinate.
- A nurse assesses a client who presents with renal calculi. Which question should the nurse ask?
a. “Do any of your family members have this problem?”
b. “Do you drink any cranberry juice?”
c. “Do you urinate after sexual intercourse?”
d. “Do you experience burning with urination?”
There is a strong association between family history and stone formation and recurrence.
Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask
whether other family members have also had renal stones. The other questions do not refer to
renal calculi but instead are questions that should be asked of a client with a urinary tract
- A nurse assesses a male client who is recovering from a urologic procedure. Which
assessment finding indicates an obstruction of urine flow?
a. Severe pain
b. Overflow incontinence
d. Blood-tinged urine
The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow.
This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence
with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of
the obstruction of urine flow.
- A nurse cares for a client with urinary incontinence. The client states, “I am so embarrassed.
My bladder leaks like a young child’s bladder.” How should the nurse respond?
a. “I understand how you feel. I would be mortified.”
b. “Incontinence pads will minimize leaks in public.”
c. “I can teach you strategies to help control your incontinence.”
d. “More women experience incontinence than you might think.”
The nurse should accept and acknowledge the client’s concerns, and assist the client to learn
techniques that will allow control of urinary incontinence. The nurse should not diminish the
client’s concerns with the use of pads or stating statistics about the occurrence of incontinence.
- A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months.
Which questions should the nurse ask? (Select all that apply.)
a. “How much water do you drink every day?”
b. “Do you take estrogen replacement therapy?”
c. “Does anyone in your family have a history of cystitis?”
d. “Are you on steroids or other immune-suppressing drugs?”
e. “Do you drink grapefruit juice or orange juice daily?”
ANS: A, B, D
Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent
cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange
juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.
- A nurse teaches clients about the difference between urge incontinence and stress incontinence.
Which statements should the nurse include in this education? (Select all that apply.)
a. “Urge incontinence involves a post-void residual volume less than 50 mL.”
b. “Stress incontinence occurs due to weak pelvic floor muscles.”
c. “Stress incontinence usually occurs in people with dementia.”
d. “Urge incontinence can be managed by increasing fluid intake.”
e. “Urge incontinence occurs due to abnormal bladder contractions.”
ANS: B, E
Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincter and cannot
tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common
after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge
incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle. Abnormal
detrusor contractions may be a result of neurologic abnormalities including dementia, or may occur with no
known abnormality. Post-void residual is associated with reflex incontinence, not with urge incontinence or
stress incontinence. Management of urge incontinence includes decreasing fluid intake, especially in the
- A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly
paired with their clinical manifestation? (Select all that apply.)
a. Stress incontinence – Urine loss with physical exertion
b. Urge incontinence – Large amount of urine with each occurrence
c. Functional incontinence – Urine loss results from abnormal detrusor contractions
d. Overflow incontinence – Constant dribbling of urine
e. Reflex incontinence – Leakage of urine without lower urinary tract disorder
ANS: A, B, D
Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising.
Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount
of urine released with each occurrence. Overflow incontinence occurs with bladder distention
and results in a constant dribbling of urine. Functional incontinence is the leakage of urine
caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results
from abnormal detrusor contractions from a neurologic abnormality.
- A nurse teaches a female client who has stress incontinence. Which statements should the
nurse include about pelvic muscle exercises? (Select all that apply.)
a. “When you start and stop your urine stream, you are using your pelvic muscles.”
b. “Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10.”
c. “Pelvic muscle exercises should only be performed sitting upright with your feet on the floor.”
d. “After you have been doing these exercises for a couple days, your control of urine will improve.”
e. “Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.”
ANS: A, B, E
The client should be taught that the muscles used to start and stop urination are pelvic muscles,
and that pelvic muscles can be strengthened by contracting and relaxing them. The client should
tighten pelvic muscles for a slow count of 10 and then relax the muscles for a slow count of 10,
and perform this exercise 15 times while in lying-down, sitting-up, and standing positions. The
client should begin to notice improvement in control of urine after several weeks of exercising
the pelvic muscles.
- A nurse assesses a client with polycystic kidney disease (PKD). Which assessment finding
should alert the nurse to immediately contact the health care provider?
a. Flank pain
b. Periorbital edema
c. Bloody and cloudy urine
d. Enlarged abdomen
Periorbital edema would not be a finding related to PKD and should be investigated further.
Flank pain and a distended or enlarged abdomen occur in PKD because the kidneys enlarge and
displace other organs. Urine can be bloody or cloudy as a result of cyst rupture or infection.
- After teaching a client with early polycystic kidney disease (PKD) about nutritional therapy,
the nurse assesses the client’s understanding. Which statement made by the client indicates a
correct understanding of the teaching?
a. “I will take a laxative every night before going to bed.”
b. “I must increase my intake of dietary fiber and fluids.”
c. “I shall only use salt when I am cooking my own food.”
d. “I’ll eat white bread to minimize gastrointestinal gas.”
Clients with PKD often have constipation, which can be managed with increased fiber, exercise,
and drinking plenty of water. Laxatives should be used cautiously. Clients with PKD should be
on a restricted salt diet, which includes not cooking with salt. White bread has a low fiber count
and would not be included in a high-fiber diet.
- A nurse evaluates a client with acute glomerulonephritis (GN). Which manifestation should the
nurse recognize as a positive response to the prescribed treatment?
a. The client has lost 11 pounds in the past 10 days.
b. The client’s urine specific gravity is 1.048.
c. No blood is observed in the client’s urine.
d. The client’s blood pressure is 152/88 mm Hg.
Fluid retention is a major feature of acute GN. This weight loss represents fluid loss, indicating that the
glomeruli are performing the function of filtration. A urine specific gravity of 1.048 is high. Blood is not
usually seen in GN, so this finding would be expected. A blood pressure of 152/88 mm Hg is too high;
this may indicate kidney damage or fluid overload.
- A nurse assesses a client who has a family history of polycystic kidney disease (PKD). For
which clinical manifestations should the nurse assess? (Select all that apply.)
b. Flank pain
c. Increased abdominal girth
ANS: B, C, E
Clients with PKD experience abdominal distention that manifests as flank pain and increased
abdominal girth. Bloody urine is also present with tissue damage secondary to PKD. Clients with
PKD often experience constipation, but would not report nocturia or dysuria.
3.A nurse reviews laboratory results for a client with glomerulonephritis. The client’s glomerular
filtration rate (GFR) is 40 mL/min as measured by a 24-hour creatinine clearance. How should
the nurse interpret this finding? (Select all that apply.)
a. Excessive GFR
b. Normal GFR
c. Reduced GFR
d. Potential for fluid overload
e. Potential for dehydration
ANS: C, D
The GFR refers to the initial amount of urine that the kidneys filter from the blood. In the healthy
adult, the normal GFR ranges between 100 and 120 mL/min, most of which is reabsorbed in the
kidney tubules. A GFR of 40 mL/min is drastically reduced, with the client experiencing fluid
retention and risks for hypertension and pulmonary edema as a result of excess vascular fluid.
- A nurse teaches a client with polycystic kidney disease (PKD). Which statements should the
nurse include in this client’s discharge teaching? (Select all that apply.)
a. “Take your blood pressure every morning.”
b. “Weigh yourself at the same time each day.”
c. “Adjust your diet to prevent diarrhea.”
d. “Contact your provider if you have visual disturbances.”
e. “Assess your urine for renal stones.”
ANS: A, B, D
A client who has PKD should measure and record his or her blood pressure and weight daily, limit salt
intake, and adjust dietary selections to prevent constipation. The client should notify the provider if urine
smells foul or has blood in it, as these are signs of a urinary tract infection or glomerular injury. The client
should also notify the provider if visual disturbances are experienced, as this is a sign of a possible berry
aneurysm, which is a complication of PKD. Diarrhea and renal stones are not manifestations or
complications of PKD; therefore, teaching related to these concepts would be inappropriate.
- A client is scheduled for a laparoscopy to remove endometriosis tissue. Which response by the
client alerts the nurse of the need for further teaching?
a. “The surgeon told me that carbon dioxide would be infused into my pelvic cavity.”
b. “There will be one or more small incisions in order to visualize all of the organs.”
c. “There will be some shoulder pain after the procedure that may last 48 hours.”
d. “I can return to jogging my 3-mile routine in a few days.”
No strenuous activity should occur for 7 days after the procedure. Carbon dioxide is infused into
the pelvic cavity to visualize the organs. There are only one or more small incisions with this
procedure. The referred shoulder pain that will occur should only last 48 hours.
- A 37-year-old Nigerian woman is at high risk for breast cancer and is considering a
prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate?
a. Discourage this surgery since the woman is still of childbearing age.
b. Reassure the client that reconstructive surgery is as easy as breast augmentation.
c. Inform the client that this surgery removes all mammary tissue and cancer risk.
d. Include support people, such as the male partner, in the decision making.
The cultural aspects of decision making need to be considered. In the Nigerian culture, the man often
makes the decisions for care of the female. Women with a high risk for breast cancer can consider
prophylactic surgery. If reconstructive surgery is considered, the procedure is more complex and will have
more complications compared to a breast augmentation. There is a small risk that breast cancer can still
develop in the remaining mammary tissue.
- A client has just returned from a right radical mastectomy. Which action by the unlicensed
assistive personnel (UAP) would the nurse consider unsafe?
a. Checking the amount of urine in the urine catheter collection bag
b. Elevating the right arm on a pillow
c. Taking the blood pressure on the right arm
d. Encouraging the client to squeeze a rolled washcloth
ANS:CHealth care professionals need to avoid the arm on the side of the surgery for blood pressure
measurement, injections, or blood draws. Since lymph nodes are removed, lymph drainage would be
compromised. The pressure from the blood pressure cuff could promote swelling. Infection could occur with
injections and blood draws. Checking urine output, elevation of the affected arm on a pillow, and
encouraging beginning exercises are all safe postoperative interventions.
- A client is discharged to home after a modified radical mastectomy with two drainage tubes.
Which statement by the client would indicate that further teaching is needed?
a. “I am glad that these tubes will fall out at home when I finally shower.”
b. “I should measure the drainage each day to make sure it is less than an ounce.”
c. “I should be careful how I lie in bed so that I will not kink the tubing.”
d. “If there is a foul odor from the drainage, I should contact my doctor.”
The drainage tubes (such as a Jackson-Pratt drain) lie just under the skin but need to be removed by the
health care professional in about 1 to 3 weeks at an office visit. Drainage should be less than 25 mL in a
day’s time. The client should be aware of her positioning to prevent kinking of the tubing. A foul odor
from the drainage may indicate an infection; the doctor should be contacted immediately.
- What comfort measure can only be performed by a nurse, as opposed to an unlicensed
assistive personnel (UAP), for a client who returned from a left modified radical mastectomy 4
a. Placing the head of bed at 30 degrees
b. Elevating the left arm on a pillow
c. Administering morphine for pain at a “4” on a 0-to-10 scale
d. Supporting the left arm while initially ambulating the client
Only the nurse is authorized to administer medications, but the UAP could inform the nurse about the rating
of pain by the client. The UAP could position the bed to 30 degrees and elevate the client’s arm on a pillow
to facilitate lymphatic fluid drainage return. The client’s arm should be supported while walking at first but
then allowed to hang straight by the side. The UAP could support the arm while walking the cl ient.
- A client is concerned about the risk of lymphedema after a mastectomy. Which response by
the nurse is best?
a. “You do not need to worry about lymphedema since you did not have radiation therapy.”
b. “A risk factor for lymphedema is infection, so wear gloves when gardening outside.”
c. “Numbness, tingling, and swelling are common sensations after a mastectomy.”
d. “The risk for lymphedema is a real threat and can be very self-limiting.”
ANS: BInfection can create lymphedema; therefore, the client needs to be cautious with activities using
the affected arm, such as gardening. Radiation therapy is just one of the factors that could cause
lymphedema. Other risk factors include obesity and the presence of axillary disease. The symptoms of
lymphedema are heaviness, aching, fatigue, numbness, tingling, and swelling, and are not common after
the surgery. Women with lymphedema live fulfilling lives.
- The nurse is taking a history of a 68-year-old woman. What assessment findings would
indicate a high risk for the development of breast cancer? (Select all that apply.)
a. Age greater than 65 years
b. Increased breast density
e. Genetic factors
ANS: A, B, E
The high risk factors for breast cancer are age greater than 65 with the risk increasing until age
80; an increase in breast densitybecause of more glandular and connective tissue; and inherited
mutations of BRCA1 and/or BRCA2 genes.Osteoporosis and multiparity are not risk factors for
breast cancer. A high postmenopausal bone density and nulliparity are moderate and low
increased risk factors, respectively.
- The nurse is formulating a teaching plan according to evidence-based breast cancer screening
guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be
included in the plan? (Select all that apply.)
a. Annual mammogram
b. Magnetic resonance imaging (MRI)
c. Breast ultrasound
d. Breast self-awareness
e. Clinical breast examination
ANS: A, D, E
Guidelines recommend a screening annual mammogram for women ages 40 years and older,
breast self-awareness, and a clinical breast examination. An MRI is recommended if there are
known high risk factors. A breast ultrasound is used if there are problems discovered with the
initial screening or dense breast tissue.
- The nurse is educating a client on the prevention of toxic shock syndrome (TSS). Which
statement by the client indicates a lack of understanding?
a. “I need to change my tampon every 8 hours during the day.”
b. “At night, I should use a feminine pad rather than a tampon.”
c. “If I don’t use tampons, I should not get TSS.”
d. “It is best if I wash my hands before inserting the tampon.”
Tampons need to be changed every 3 to 6 hours to avoid infection by such organisms as
Staphylococcus aureus. All of the other responses are correct: use of feminine pads at night, not
using tampons at all, and washing hands before tampon insertion are all strategies to prevent
- A client is admitted to the emergency department with toxic shock syndrome. Which action by
the nurse is the most important?
a. Administer IV fluids to maintain fluid and electrolyte balance.
b. Remove the tampon as the source of infection.
c. Collect a blood specimen for culture and sensitivity.
d. Transfuse the client to manage low blood count.
The source of infection should be removed first. All of the other answers are possible
interventions depending on the client’s symptoms and vital signs, but removing the tampon is the
1.A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms.
Which actions by the nurse are the most appropriate at this time? (Select all that apply.)
a. Reduce the pain by low-level heat.
b. Discuss the high risk of infertility with this diagnosis.
c. Relieve anxiety by relaxation techniques and education.
d. Discuss in detail the side effects of laparoscopic surgery.
e. Suggest resources such as the Endometriosis Association.
ANS: A, C, E
With endometriosis, pain is the predominant symptom, with anxiety occurring because of the
diagnosis. Interventions should be directed to pain and anxiety relief, such as low-level heat,
relaxation techniques, and education about the pathophysiology and possible treatment of
endometriosis. The nurse could suggest resources to give more information about the diagnosis.
Discussion of the possibility of infertility and side effects of laparoscopic surgery is premature
and may increase the anxiety.
- The nurse is taking the history of a 24-year-old client diagnosed with cervical cancer. What
possible risk factors would the nurse assess? (Select all that apply.)
b. Multiple sexual partners
c. Poor diet
e. Younger than 18 at first intercourse
ANS: A, B, C, E
Smoking, multiple sexual partners, poor diet, and age less than 18 for first intercourse are all risk
factors for cervical cancer. Nulliparity is a risk factor for endometrial cancer.
- The nurse is teaching a client with benign prostatic hyperplasia (BPH). What statement
indicates a lack of understanding by the client?
a. “There should be no problem with a glass of wine with dinner each night.”
b. “I am so glad that I weaned myself off of coffee about a year ago.”
c. “I need to inform my allergist that I cannot take my normal decongestant.”
d. “My normal routine of drinking a quart of water during exercise needs to change.”
This client did not associate wine with the avoidance of alcohol, and requires additional teaching. The nurse
must teach a client with BPH to avoid alcohol, caffeine, and large quantities of fluid in a short amount of
time to prevent overdistention of the bladder. Decongestants also need to be avoided to lower the chance
for urinary retention.
- A 19-year-old female is asking the nurse about the vaccine for human papilloma virus (HPV).
Which statement by the nurse is accurate?
a. “Gardasil protects against all HPV strains.”
b. “You are too young to receive the vaccine.”
c. “Only females can receive the vaccine.”
d. “This will lower your risk for cervical cancer.”
Gardasil is used to provide immunity for HPV types 6, 11, 16, and 18 that are high risk for
cervical cancer and warts. The vaccine is recommended for people ages 10 to 26 years.
Revision 3 – Nursing Final
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