Online Practice Test 48

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 48 > NCLEX® Review Date/Time Submitted: August 1, 2012 at 2:14 PM (UTC/GMT)

Summary of Results 60% Correct of 10 Scored items: 6 Correct:  60% 4 Incorrect:  40% More information about scoring

1.		A client comes to the primary care provider's office with the complaints of urinating all the time, pain on urination, small amounts of urine being passed when voiding, and a foul smell to the urine. A urine specimen has been sent for analysis. Based on the signs and symptoms expressed by the client, which of the following health problems would be anticipated? Your Answer: Urinary tract infection
		Objective: Identify common causes of selected urinary problems. Rationale: The noted signs and symptoms help to identify the problem of urinary tract infection. The signs and symptoms noted are not common with the other diseases listed. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		An appropriate health goal for clients with urinary elimination problems would include:  Your Answer: Preventing associated risks, such as infections and fluid and electrolyte imbalances.
		Objective: Develop nursing diagnoses, desired outcomes, and interventions related to urinary elimination. Rationale: Preventing associated risks related to urinary disease is the only appropriate goal noted. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		Which nursing assessment in the home care environment for clients with urinary elimination problems is inappropriate? Your Answer: No dietary restrictions needed
		Objective: Describe nursing assessment of urinary function including subjective and objective data. Rationale: Dietary guides related to fiber and fluid balance are given to clients with this problem. The remaining actions are noted in the assessment guide, and are appropriate measures to use with clients. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		The nurse is requested to perform teaching to a client in the Emergency Department related to the diagnosis of a urinary tract infection. An intervention to be followed by the client includes:  Your Answer: Voiding pattern in the course of the day has no significance with this problem. Correct Answer: Avoid tight-fitting pants or clothing
		Objective: Delineate ways to prevent urinary infection. Rationale: Tight-fitting clothing creates irritation to the urethra and prevents ventilation of the perineal area. It is recommended that eight glasses of water be drunk to flush out the urinary system. Avoid harsh soaps, bubble bath, powders, and sprays in the perineal area, because they can have an irritating effect on the urethra, encouraging inflammation and a bacterial infection. Practice frequent voiding (q 2-3 hours) to flush bacteria out other the urethra and prevent organisms from ascending into the bladder. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		Urinary incontinence is not a normal part of aging. An intervention used by nurses to assist clients to regain or maintain continence with individuals suffering from this problem would not include: Your Answer: Fluid restriction
		Objective: Develop nursing diagnoses, desired outcomes, and interventions related to urinary elimination. Rationale: Fluids would be encouraged, to allow the kidneys to be flushed and urine to be formed. Bladder training requires that the client postpone voiding, resist or inhinbit the sensation of urgency, and void according to a timetable, rather than according to an urge. Habit training is also referred to timed or scheduled voiding. There is no attempt to motivate the client to delay voiding if the urge occurs. Prompted voiding supplements habit training by encouraging the client to try to use the toilet and reminding the client when to void. Nursing Process: Implememtation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
6.		Urinary catheterization is carried out for clients only when absolutely necessary. Which of the following candidates/situations would not warrant the need for this procedure? Your Answer: To collect a random urine specimen for evaluation
		. Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: Collection of a random urine specimen is not routinely obtained by use of the process of catheterization. The other candidates/situations are appropriate uses of this technique. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		The goal of nursing care of the client with an indwelling catheter and continuous drainage is largely directed at preventing infection of the urinary tract and encouraging urinary flow through the drainage system. Which of the following interventions encouraged by nurses working with these clients would not be appropriate in meeting this goal? Your Answer: Encouraging the client to eat foods that increase the acid in the urine Correct Answer: Changing indwelling catheters every 72 hours.
		Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: Retention catheters are removed after their purpose is achieved; routine changing of the catheter or drainage system is not recommended. Large amounts of fluid ensure a large urine output, which keeps the bladder flushed out and decreases the likelihood of urinary stasis and subsequent infection. Eating foods that increase the acid in urine helps to reduce the risk of urinary tract infections and stone formation. Hygiene care related to catheters is set by hospital policy. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		A urinary diversion is the surgical rerouting of urine from the kidneys to a site other than the bladder. Which type of client would this type of procedure would benefit from this procedure?  Your Answer: A client with kidney stones Correct Answer: An abdominal trauma victim
		Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: The abdominal trauma victim is the only appropriate answer here. The remaining problems can be treated with less traumatic care measures. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		A practice guideline for nurses to use in preventing catheter-associated urinary infection includes which of the instructions listed below? Your Answer: Prevent contamination of the catheter with feces in the incontinent client.
		Objective: Explain the care of clients with retention catheters or urinary diversions. Rationale: Keeping the perineal area free of feces eliminates the possible spread of any bacteria that may colonize in the feces and travel up the catheter to the bladder. Sterile or aseptic technique is used when inserting Foley catheters into clients to prevent the spread of infection with the process. Catheter tubing should not be disconnected once put into use. Connections are usually taped to help secure their seal. Wearing gloves with this procedure is part of the practice of Universal Precautions utilized when health care workers come in contact with most tubes and body fluids. Nursing Process: Implementation Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
10.		The nurse is counseling a young mother who complains of having stress incontinence continuing for three months after her pregnancy. It has been recommended that she practice pelvic muscle exercises to strengthen her bladder muscles. What action would the nurse recommend to this client in order to perform this activity correctly? Your Answer: Moving her bowels Correct Answer: Stopping urination midstream
		Objective: Develop nursing diagnoses, desired outcomes, and interventions related to urinary elimination Rationale: Stopping the flow of urination midstream focuses on the muscle used to control this activity. The remaining answers do not affect this muscle in the same manner. Nursing Process: Implementation Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection