Question

A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

Answer 1

Correct Answers:

Caffeinated beverages

Rationale :

💠 Caffeine is a known bladder irritant that stimulates the bladder muscle.

💠 It increases urinary urgency and frequency, worsening incontinence symptoms.

💠 Caffeine has a diuretic effect, increasing urine production.

💠 It can heighten bladder sensitivity, leading to leakage episodes.

💠 Common sources include coffee, tea, energy drinks, and colas.

Dairy products

💠 Dairy products are not typical bladder irritants.

💠 They are generally well tolerated unless a client has a specific intolerance.

Red meat

💠 Red meat does not irritate the bladder lining.

💠 It is not associated with increased urinary urgency or frequency.

Fresh vegetables

💠 Fresh vegetables are bladder-friendly foods.

💠 They do not stimulate bladder contractions or irritation.

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Answer 2

Correct Answers:

Placing the drainage bag on the side rail of the patient's bed

Rationale :

💠 Drainage bag positioning must always be below the level of the bladder to allow continuous gravity drainage; placing it on a side rail elevates the bag above bladder level.

💠 Elevating the drainage bag increases the risk of urine reflux, which can allow contaminated urine to flow back into the bladder.

💠 Urine backflow is a major contributor to catheter-associated urinary tract infections (CAUTIs) and violates infection-control standards.

💠 Side rails move frequently during repositioning, which makes them an unsafe and unstable location for a drainage bag.

💠 This action reflects improper catheter care, requiring the nurse to intervene immediately to prevent patient harm.

Kinking the catheter tubing to obtain a urine specimen

💠 Temporary kinking below the sampling port allows urine to collect for a sterile specimen.

💠 When done briefly and released promptly, it does not compromise catheter function.

Securing the catheter tubing to the patient’s thigh

💠 Securing the tubing prevents tugging and urethral trauma, which is best practice.

💠 This promotes comfort and catheter stability.

Emptying the drainage bag when half full

💠 Emptying before the bag is full prevents backflow and excess weight on the catheter.

💠 This reflects appropriate monitoring and maintenance.

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Answer 3

Correct Answers:

0.45% sodium chloride (1/2 NS)

Rationale :

💠 Hypotonic IV solution refers to a fluid with a lower osmolality than blood plasma, causing water to move into cells.

💠 0.45% sodium chloride contains less sodium than plasma, making it a true hypotonic solution once infused.

💠 Hypotonic fluids are commonly used to treat cellular dehydration, allowing cells to rehydrate and swell appropriately.

💠 This solution promotes intracellular fluid shifts, which is the defining therapeutic goal when hypotonic fluids are prescribed.

💠 The provider’s order specifically requires a solution that lowers extracellular osmolality, a criterion met by 0.45% NS.

0.9% sodium chloride (NS)

💠 0.9% NS has an osmolality similar to plasma, classifying it as isotonic, not hypotonic.

💠 Isotonic fluids expand the intravascular space without causing cellular fluid shifts.

Lactated Ringer’s (LR)

💠 LR is an isotonic crystalloid, closely resembling plasma electrolyte composition.

💠 It is used for volume replacement, not for shifting fluid into cells.

Dextrose 5% in Lactated Ringer’s (D5LR)

💠 D5LR is considered hypertonic initially due to dextrose content.

💠 It does not function as a hypotonic solution during administration.

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Answer 4

Correct Answers:

Keep the bed in the lowest position
Placing a high risk for falls armband on the patient
Maintain call light within reach of the patient

Rationale :

💠 Fall precautions are safety interventions designed to reduce injury risk by modifying the environment and improving patient awareness and access to help.

💠 Keeping the bed in the lowest position reduces the distance of a potential fall, lowering the risk of serious injury.

💠 A high-risk for falls armband provides a visual alert to all healthcare staff that the patient requires extra safety measures.

💠 Maintaining the call light within reach allows the patient to request assistance before attempting to ambulate independently.

💠 These interventions work together to prevent unassisted movement, a major cause of inpatient falls.

💠 Fall precautions emphasize frequent accessibility and visibility, not restriction or neglect.

Placing all four side rails in the “up” position

💠 Raising all four side rails is considered a restraint, not a standard fall-prevention strategy.

💠 This can increase injury risk if the patient attempts to climb over the rails.

Checking on the patient once a shift

💠 Fall-risk patients require frequent rounding, not once-per-shift monitoring.

💠 Infrequent checks increase the chance of unsupervised ambulation and falls.

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Answer 5

Correct Answers:

"You need to drink plenty of fluid and eat a diet high in fiber."

Rationale :

💠 Constipation prevention is a key part of opioid teaching because hydrocodone slows gastrointestinal motility.

💠 Increased fluids help soften stool and support normal bowel movement while taking narcotics.

💠 A high-fiber diet promotes bowel regularity and reduces the risk of opioid-induced constipation.

💠 Constipation is one of the most common and expected side effects of opioid analgesics, even with short-term use.

💠 Proactive bowel management improves comfort, adherence, and safety during recovery at home.

“Be sure to eat a meal high in fat before taking the medication, to avoid a stomach ulcer.”

💠 Opioids do not cause stomach ulcers, and high-fat meals are not required.

💠 This teaching reflects incorrect medication guidance.

“As your pain severity lessens, you will begin to give yourself once-daily intramuscular injections.”

💠 Hydrocodone is prescribed for oral administration, not intramuscular injection.

💠 This statement is unsafe and inaccurate for discharge teaching.

“Narcotics can be addictive, so do not take them unless you are in severe pain.”

💠 Pain medication should be taken as prescribed, not based on fear of addiction alone.

💠 Inadequate pain control can delay healing and mobility.

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Answer 6

Correct Answers:

Tingling of extremities with possible tetany

Rationale :

💠 Severely low calcium (hypocalcemia) is evident with a calcium level of 4.5 mg/dL, which is well below the normal range and directly affects neuromuscular excitability.

💠 Low calcium causes increased nerve membrane permeability, leading to spontaneous nerve firing that manifests as tingling (paresthesias) in the fingers, toes, and around the mouth.

💠 Hypocalcemia increases the risk of tetany, characterized by involuntary muscle contractions, spasms, and possible laryngospasm.

💠 Classic clinical signs associated with hypocalcemia include neuromuscular irritability, which aligns with tingling and tetany rather than muscle weakness or reflex depression.

💠 Normal sodium (145 mEq/L) and potassium (4.5 mEq/L) levels rule out symptoms related to volume depletion or potassium imbalance, pointing clearly to calcium as the cause.

Decreased deep tendon reflexes

💠 Decreased reflexes are more commonly associated with hypercalcemia, not hypocalcemia.

💠 Low calcium causes hyperreflexia, not diminished reflex responses.

Light-headedness when standing up

💠 This finding is related to orthostatic hypotension or volume depletion.

💠 The sodium level is normal, making this assessment finding unlikely.

Weak quadriceps muscles

💠 Muscle weakness is more consistent with hypokalemia or neuromuscular disorders.

💠 The potassium level is within normal limits, making this option inconsistent.

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Answer 7

Correct Answers:

pH 7.53, PaCO2 30 mm Hg. HCO3-24 mEq/L

Rationale :

💠 Respiratory alkalosis is defined by an elevated pH with a decreased PaCO₂ due to excessive carbon dioxide loss from the lungs.

💠 A pH of 7.53 confirms alkalemia, which is required to diagnose alkalosis.

💠 A PaCO₂ of 30 mm Hg is below normal, indicating hyperventilation, the primary cause of respiratory alkalosis.

💠 The normal bicarbonate level (24 mEq/L) shows this is an uncompensated or early respiratory disorder.

💠 This pattern reflects a primary respiratory problem, not a metabolic imbalance.

pH 7.35, PaCO₂ 35 mm Hg, HCO₃⁻ 26 mEq/L

💠 The pH is normal, which does not indicate alkalosis.

💠 Both PaCO₂ and HCO₃⁻ are within or near normal limits.

pH 7.25, PaCO₂ 48 mm Hg, HCO₃⁻ 23 mEq/L

💠 The low pH indicates acidosis, not alkalosis.

💠 The elevated PaCO₂ is consistent with respiratory acidosis.pH 7.60, PaCO₂ 40 mm Hg, HCO₃⁻ 30 mEq/L

💠 The high bicarbonate level indicates a metabolic cause, not respiratory.

💠 Normal PaCO₂ rules out a primary respiratory disorder.

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Answer 8

Correct Answers:

Compassion fatigue

Rationale :

💠 Compassion fatigue occurs when prolonged exposure to patients’ suffering leads to emotional exhaustion, reduced empathy, and difficulty feeling sympathy.

💠 Caring for multiple dying clients places hospice nurses at high risk due to continuous emotional demands and repeated exposure to grief.

💠 A hallmark sign is emotional numbness, where the nurse feels detached or unable to connect compassionately with patients.

💠 This condition reflects depletion of emotional reserves, not a lack of caring or professional commitment.

💠 Early recognition is essential to prevent progression to burnout and to promote self-care and professional support.

Post-traumatic stress disorder (PTSD)

💠 PTSD is associated with exposure to a traumatic event involving threat to life or safety.

💠 Symptoms include flashbacks, nightmares, and hypervigilance, which are not described here.

Adventitious stress

💠 This is not a recognized clinical or nursing diagnosis.

💠 It does not describe emotional exhaustion related to caregiving.

Prolonged grief disorder

💠 Prolonged grief involves persistent grief after personal loss, not occupational exposure.

💠 The nurse is experiencing work-related emotional depletion, not unresolved personal bereavement.

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Answer 9

Correct Answers:

Pursed-lip breathing helps prevent alveolar collapse by encouraging prolonged exhalation through pursed lips.

Rationale :

💠 Pursed-lip breathing is designed to prolong exhalation, which helps keep airways open longer in patients with COPD.

💠 By exhaling slowly through pursed lips, back-pressure is created in the airways, preventing alveolar collapse.

💠 This technique reduces air trapping and improves carbon dioxide elimination, a key issue in COPD.

💠 Pursed-lip breathing enhances ventilation efficiency and decreases the sensation of dyspnea.

💠 It allows patients to maintain better control of breathing, especially during exertion or episodes of shortness of breath.

The technique requires the patient to inhale through pursed lips and exhale quickly through the nose

💠 Inhalation should occur through the nose, not pursed lips.

💠 Rapid exhalation worsens air trapping rather than improving gas exchange.

Pursed-lip breathing is mainly used to decrease the heart rate

💠 The primary purpose is respiratory support, not cardiac rate control.

💠 Any reduction in heart rate is secondary to improved oxygenation and reduced anxiety.

Pursed-lip breathing involves rapid inhalation and exhalation

💠 Rapid breathing increases respiratory fatigue and worsens COPD symptoms.

💠 The technique emphasizes slow, controlled breathing, not speed.

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Answer 10

Correct Answers:

Document objective data, leaving out opinions.
Put the date and time on all entries,

Rationale :

💠 Documenting objective data ensures that charting reflects observable, measurable facts rather than personal opinions or assumptions.

💠 Objective documentation improves clarity and credibility, making the record legally sound and clinically useful.

💠 Dating and timing every entry establishes a clear chronological record of care provided.

💠 Accurate time stamps are critical for continuity of care, audits, and potential legal review.

💠 These practices protect both the patient’s safety and the nurse’s professional accountability.

Use as many abbreviations as possible

💠 Excessive or non-approved abbreviations can cause misinterpretation and errors.

💠 Only facility-approved abbreviations should ever be used.

Cover errors with correction fluid, and write in the correct information

💠 Using correction fluid is legally prohibited because it suggests tampering.

💠 Errors must be corrected using proper error-correction procedures per policy.

Wait until the end of the shift to document

💠 Delayed documentation increases the risk of inaccurate or incomplete records.

💠 Documentation should be done as soon as possible after care is provided.

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MSN DE5320 Fall 2025

No.

1 :
A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

2 :
A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

3 :
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?

4 :
The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select all that apply)

5 :
A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide?

6 :
Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

7 :
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?

8 :
A hospice nurse tells another nurse that they are feeling overwhelmed after caring for multiple clients who are dying and reports having difficulty feeling sympathy for their clients. The nurse has manifestations of which of the following conditions?

9 :
Which of the following statements accurately describes the purpose and technique of pursed-lip breathing in patients with COPD?

10 :
A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select All that Apply.)

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MSN DE5320 Fall 2025

No.

1 : A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

2 : A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

3 : The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?

4 : The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select all that apply)

5 : A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide?

6 : Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

7 : Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?

8 : A hospice nurse tells another nurse that they are feeling overwhelmed after caring for multiple clients who are dying and reports having difficulty feeling sympathy for their clients. The nurse has manifestations of which of the following conditions?

9 : Which of the following statements accurately describes the purpose and technique of pursed-lip breathing in patients with COPD?

10 : A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select All that Apply.)

1 :
A nurse is teaching a client who has urinary incontinence about avoiding foods and beverages that can cause bladder irritation. The nurse should include that which of the following foods and beverages is a bladder irritant?

2 :
A nurse is evaluating a nursing assistive personnel's (AP) care for a patient with an indwelling catheter. Which action by the AP will cause the nurse to intervene?

3 :
The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare?

4 :
The client has been admitted and placed on fall precautions. The nurse explains to the patient that interventions for the precautions include: (Select all that apply)

5 :
A nurse is providing discharge teaching for a patient with a fractured humerus. The patient is going home with a prescription for hydrocodone. Which important patient education should the nurse provide?

6 :
Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

7 :
Which blood gas result will the nurse expect to observe in a patient with respiratory alkalosis?

8 :
A hospice nurse tells another nurse that they are feeling overwhelmed after caring for multiple clients who are dying and reports having difficulty feeling sympathy for their clients. The nurse has manifestations of which of the following conditions?

9 :
Which of the following statements accurately describes the purpose and technique of pursed-lip breathing in patients with COPD?

10 :
A charge nurse is reviewing documentation with a group of newly licensed nurses. Which of the following legal guidelines should be followed when documenting in a client's record? (Select All that Apply.)