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    Exam Review

    1. A nurse is assessing the characteristics of a patient's pain. Which question is not included in the pain assessment?
      A)How can it hurt? I just gave you pain medication an hour ago.
      B)Could you rate your pain on a scale of 0 to 10?
      C)How often does it recur?
      D)What does the pain feel like?
    2. A patient who has type 2 diabetes for 26 years is beginning to experience peripheral neuropathy in the feet and lower leg. The nurse is providing education to the patient to prevent injury to the feet by wearing shoes or slippers when walking. Which statement by the nurse best explains the rationale for this instruction?
      A)Wearing shoes blocks pain perception and helps you adapt to pain, which ends up protecting your feet.
      B)The neurological gates open when wearing shoes, which protects your feet.
      C)If you step on something without shoes, you might not feel it; this could possibly cause injury to your foot.
      D)Shoes provide nonpharmacological pain relief to people with diabetes and peripheral neuropathy.
    3. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
      A)Kinking the catheter tubing to obtain a sterile urine specimen.
      B)Emptying the colostomy drainage bag when 3/4 full.
      C)Assessing placement of a Foley and securing the catheter tubing to the patient's thigh.
      D)Placing the urinary catheter bag on the bed frame of the patient's bed after ambulation.
    4. A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?
      A)Stop the enema and document that the client did not tolerate the procedure.
      B)Lower the height of the solution container.
      C)Encourage the client to bear down.
      D)Allow the client to expel some fluid before continuing.
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    Exam Review

    1. Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective?
      A)Bladder distention with tenderness.
      B)Blood clots or sediment in the drainage bag.
      C)Bright red urine turns pink in the tubing.
      D)Output is smaller than the amount instilled.
    2. A client is receiving pain medications as needed. Which of the following interventions are important following the administration of pain medication? (Select all that apply)(SATA)
      A)Reassess pain score.
      B)Assess the surgical site.
      C)Reassess vital signs.
      D)Assess for bowel sounds.
      E)Assess level of consciousness.
    3. A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client?
      A)Incontinence.
      B)Low back pain.
      C)Confusion.
      D)Urinary retention.
    4. A patient who had a motor vehicle crash 2 days ago is experiencing pain and is receiving patient-controlled analgesia (PCA). Which assessment finding indicates effective pain management with the PCA?
      A)The patient has sufficient medication left in the PCA syringe.
      B)The patient is sleeping and is difficult to arouse.
      C)The patient rates pain at a level of 2 on a 0 to 10 scale.
      D)The patient presses the control button to deliver pain medication.
    Page 2 of 12

    Exam Review

    1. A nurse is teaching a patient about patient-controlled analgesia (PCA). Which statement made by the patient indicates to the nurse that teaching is effective?
      A)I will only need to be on this pain medication.
      B)I need the nurse to notify me when it is time for another dose.
      C)I feel less anxiety about the possibility of overdosing.
      D)I can receive the pain medication as frequently as I need to.
    2. A nurse is caring for a patient with an ileostomy. Which action by the nurse is most appropriate?
      A)Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive.
      B)Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma.
      C)Emptying the pouch if it is more than one-third to one-half full.
      D)Changing the skin barrier portion of the ostomy pouch daily.
    3. A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?
      A)Perform a bladder scan.
      B)Increase fluids.
      C)Provide assistance to the bathroom.
      D)Insert a straight catheter.
    4. The nurse anticipates a suprapubic catheter for which patient?
      A)A patient with a recent hysterectomy.
      B)A patient with menopause.
      C)A patient with a urethral stricture.
      D)A patient with an appendectomy.
    Page 3 of 12

    Exam Review

    1. The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?
      A)Ascending colon.
      B)Descending colon.
      C)Sigmoid colon.
      D)Transverse colon.
    2. A nurse is caring for a patient who recently had abdominal surgery and is experiencing severe pain. The patient’s blood pressure is 110/60 mmHg, and heart rate is 60 beats/min. Additionally, the patient does not appear to be in any distress. Which response by the nurse is most therapeutic?
      A)I will go get you some narcotic pain relievers immediately.
      B)Your vitals do not show that you are having pain; can you describe your pain?
      C)You do not look like you are in pain.
      D)What would you like to try to alleviate your pain?
    3. A nurse is teaching a health class about colorectal cancer. Which information is incorrect and should not be included in the teaching session?
      A)A risk factor is high intake of animal fats or red meat.
      B)A warning sign is rectal bleeding.
      C)A risk factor is smoking.
      D)A warning sign is diarrhea.
    4. The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action?
      A)The patient will not interrupt the procedure by asking to go to the bathroom.
      B)To check the patency after abdominal surgery.
      C)Anesthetics can decrease bladder contractility and cause urinary retention.
      D)The patient may void uncontrollably during the procedure.
    Page 4 of 12

    Exam Review

    1. A patient is being seen for complaints of severe flank pain lasting for 2 days. The emergency department physician suspects that the patient has renal calculi. Which of the following tests would the nurse expect the health care provider to order?
      A)Endoscopy
      B)Ultrasound
      C)Chest radiography
      D)Intravenous pyelogram or Computerized Tomography (CT)
    2. A patient asks about treatment for stress urinary incontinence. Which is the nurse’s best response?
      A)Perform pelvic floor muscle exercises.
      B)Avoid voiding frequently.
      C)Wear an adult diaper.
      D)Drink cranberry juice.
    3. A nurse is obtaining a 24-hour urine specimen collection from the patient. Which action should the nurse take?
      A)Testing the urine sample with a reagent strip by dipping in the urine
      B)Withholding all patient medications for the day
      C)Asking the patient to void and discarding that urine to start the collection
      D)Irrigating the sample as needed with sterile solution
    4. When caring for clients in pain, the nurse needs to understand that clients:
      A)Will demonstrate vital signs consistent with their intensity of pain
      B)Sometimes complain of pain for no reason
      C)Need to know that the nurse believes what they say about their pain
      D)Who are in pain will request pain medication
    Page 5 of 12

    Exam Review

    1. Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine?
      A)Reduced specific gravity
      B)Abnormal blood sugar
      C)Fever with chills
      D)Increased blood pressure
    2. A patient calls the office to tell you that his or her urine has changed orange in color. The best response of the nurse is which of the following?
      A)Did you recently drink a lot of cranberry juice?
      B)Did you recently start taking any new medication?
      C)Please make an appointment with the office right away.
      D)Have you noticed any blood on the tissue when you wipe yourself?
    3. A patient expresses concerns over having black stool. The fecal occult blood test is negative. Which response by the nurse is most appropriate?
      A)You should schedule a colonoscopy as soon as possible.
      B)This is probably a false negative.
      C)Are you under a lot of stress?
      D)Do you take iron supplements?
    4. A nurse is planning care for a client who is postoperative and at risk for paralytic ileus. Which of the following interventions should the nurse plan to take to promote peristalsis?
      A)Offer the client the bedpan every 2 hr.
      B)Increase ambulation.
      C)Increase protein intake
      D)Decrease fluid intake.
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