Exam 2: NR224/ NR 224 (Latest 2023/ 2024 Update) Fundamentals Skills Exam Prep| Questions and Verified Answers - Chamberlain
QUESTION
1. A patient is
... [Show More] scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.)
1. Ask the patient about any allergies and reactions.
2. Instruct the patient that a full bladder is required for the test.
3. Instruct the patient to save all urine in a special container.
4. Ensure that informed consent has been obtained.
5. Instruct the patient that facial flushing can occur when the contrast media is given.
Answer:
1. Ask the patient about any allergies and reactions.
QUESTION
2. What is a critical step when inserting an indwelling catheter into a male patient?
1. Slowly inflate the catheter balloon with sterile saline.
2. Secure the catheter drainage tubing to the bedsheets.
3. Advance the catheter to the bifurcation of the drainage and balloon ports.
4. Advance the catheter until urine flows, then insert ¼ inch more.
Answer:
3. Advance the catheter to the bifurcation of the drainage and balloon ports.
QUESTION
3. Which instruction should the nurse give the assistive personnel (AP) concerning a patient who has had an indwelling urinary catheter removed that day?
1. Limit oral fluid intake to avoid possible urinary incontinence.
2. Expect patient complaints of suprapubic fullness and discomfort.
3. Report the time and amount of first voiding.
4. Instruct patient to stay in bed and use a urinal or bedpan
Answer:
3. Report the time and amount of first voiding.
QUESTION
4. A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention(s)? (Select all that apply.)
1. Increase the rate of the CBI.
2. Assess the patency of the drainage system.
3. Measure urine output.
4. Assess vital signs.
5. Administer ordered pain medication.
Answer:
2. Assess the patency of the drainage system.
3. Measure urine output.
QUESTION
5. An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?
1. Recommend that she be evaluated for an overactive bladder (OAB) medication.
2. Establish a toileting schedule.
3. Recommend that she be evaluated for an indwelling catheter.
4. Start a bladder-retraining program.
Answer:
2. Establish a toileting schedule.
QUESTION
6. What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.)
1. Maintain regular bowel elimination.
2. Limit water intake to 1 to 2 glasses a day.
3. Wear cotton underwear.
4. Cleanse the perineum from front to back.
5. Practice pelvic muscle exercise (Kegel) daily.
Answer:
1. Maintain regular bowel elimination.
3. Wear cotton underwear.
4. Cleanse the perineum from front to back.
QUESTION
7. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.
1. Insert and advance catheter.
2. Lubricate catheter.
3. Inflate catheter balloon.
4. Cleanse urethral meatus with antiseptic solution.
5. Drape patient with the sterile square and fenestrated drapes.
6. When urine appears, advance another 2.5 to 5 cm.
7. Prepare sterile field and supplies.
8. Gently pull catheter until resistance is felt.
9. Attach drainage tubing.
Answer:
5, 7, 2, 4, 1, 6, 3, 8, 9;
5. Drape patient with the sterile square and fenestrated drapes.
7. Prepare sterile field and supplies.
2. Lubricate catheter.
4. Cleanse urethral meatus with antiseptic solution.
1. Insert and advance catheter.
6. When urine appears, advance another 2.5 to 5 cm.
3. Inflate catheter balloon.
8. Gently pull catheter until resistance is felt.
9. Attach drainage tubing.
QUESTION
8. Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.)
1. Attach a 3-mL syringe to the inflation port.
2. Allow the balloon to drain into the syringe by gravity.
3. Initiate a voiding record/bladder diary.
4. Pull the catheter quickly.
5. Clamp the catheter before removal.
Answer:
2. Allow the balloon to drain into the syringe by gravity.
3. Initiate a voiding record/bladder diary.
QUESTION
9. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)?
1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution
2. Hanging the urinary drainage bag below the level of the bladder
3 Emptying the urinary drainage bag daily
4. Irrigating the urinary catheter with sterile water
Answer:
2. Hanging the urinary drainage bag below the level of the bladder
QUESTION
10. There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next?
1. Remove the catheter and start all over with a new kit and catheter.
2. Leave the catheter there and start over with a new catheter.
3. Pull the catheter back and reinsert at a different angle.
4. Ask the patient to bear down and insert the catheter farther.
Answer:
2. Leave the catheter there and start over with a new catheter.
QUESTION
__________________________ is narrowing of the tracheal lumen due to scar formation resulting from irritation of the tracheal mucosa from the tracheal tube cuff. [Show Less]