Question

A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

Answer 1

Correct Answers:

Overflow

Rationale :

🫁 Overflow incontinence occurs when the bladder becomes overdistended and is unable to empty completely, causing frequent leakage of small amounts of urine.

🫁 The client’s palpable bladder indicates urinary retention with bladder distention, which is a key finding of overflow incontinence.

🫁 Postoperative clients are at increased risk for urinary retention due to effects of anesthesia, medications (especially opioids), and decreased bladder muscle tone.

🫁 When the bladder becomes too full, urine leaks out involuntarily because the pressure exceeds the bladder’s ability to hold urine.

🫁 Clients with overflow incontinence often report:

Dribbling urine

Incomplete bladder emptying

Frequent small voids

Weak urine stream

🫁 The nurse should assess bladder volume, monitor intake and output, and evaluate for urinary retention.

🫁 Management may include interventions such as bladder scanning, scheduled toileting, or catheterization if prescribed.

🫁 Therefore, frequent small urine leakage with a distended palpable bladder indicates overflow incontinence.

❌ Incorrect Answers

Stress

🫁 Stress incontinence occurs when increased abdominal pressure causes urine leakage, such as with coughing, sneezing, or lifting.

🫁 It is not associated with bladder distention or urinary retention.

Urge

🫁 Urge incontinence involves a sudden, strong need to urinate followed by involuntary urine loss.

🫁 The bladder is usually not enlarged or palpable.

Functional

🫁 Functional incontinence occurs when a person cannot reach or use the toilet due to physical or cognitive limitations.

🫁 It does not involve bladder overfilling or urinary retention.

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Answer 2

Correct Answers:

"It could be helpful for you to attend a support group for people who have burn injuries.

Rationale :

🫁 Clients with extensive burn injuries may experience body image disturbance, grief, anxiety, and depression related to changes in appearance and function.

🫁 Support groups allow burn survivors to connect with others who have experienced similar challenges and provide emotional encouragement.

🫁 Peer support can help clients develop coping strategies and improve acceptance of physical changes.

🫁 Burn recovery involves not only physical healing but also psychological adjustment to scars, altered appearance, and possible lifestyle changes.

🫁 Support groups provide a safe environment where clients can discuss feelings about self-esteem, relationships, and social interactions.

🫁 The nurse should recognize that emotional healing may continue long after wounds have healed.

🫁 Encouraging participation in support resources promotes adaptation, confidence, and improved quality of life.

🫁 Therefore, recommending a burn injury support group is an appropriate therapeutic nursing intervention.

❌ Incorrect Answers

"It is okay to not want to touch the burned areas of your body."

🫁 Avoiding the burned areas may reinforce negative feelings and delay adjustment to body changes.

🫁 The client should be encouraged to gradually participate in wound care and body acceptance activities as tolerated.

"Cosmetic surgery should be performed within the next year to be effective."

🫁 Cosmetic or reconstructive procedures are individualized and may not be performed within a specific timeframe.

🫁 Surgery timing depends on wound healing, scar maturation, and the client’s overall condition.

"Reconstructive surgery can completely restore your previous appearance."

🫁 Reconstructive surgery can improve function and appearance but cannot always completely restore the client’s previous appearance.

🫁 Providing unrealistic expectations may interfere with emotional adjustment and coping.

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Answer 3

Correct Answers

Blank 1 Correct Option: are having numbness in their hands and feet
Blank 2 Correct Option: IV iron dextran

Rationale :

✅ Have noticed any dark, tarry stools

🫁 The client’s laboratory findings indicate iron deficiency anemia (Hgb 8.1 g/dL, Hct 27%, low MCV of 70 fL, and low transferrin saturation).

🫁 Crohn’s disease can cause chronic gastrointestinal inflammation and bleeding, leading to iron loss.

🫁 Dark, tarry stools (melena) may indicate occult gastrointestinal bleeding, which can contribute to iron deficiency.

🫁 The nurse should assess for signs of blood loss because ongoing bleeding can worsen anemia.

🫁 Identifying the source of iron loss helps guide treatment and prevent recurrence.

🫁 The client’s fatigue, pallor, tachycardia, and shortness of breath are consistent with decreased oxygen-carrying capacity from anemia.

🫁 Therefore, asking about dark, tarry stools is an appropriate assessment question.

✅ IV iron dextran

🫁 The client has findings consistent with iron deficiency anemia, likely related to Crohn’s disease and possible impaired intestinal absorption after small bowel resection.

🫁 Iron deficiency is supported by:

Low hemoglobin

Low hematocrit

Low MCV (microcytic anemia)

Low transferrin saturation

🫁 After small bowel surgery, oral iron absorption may be reduced, making IV iron replacement more effective.

🫁 Iron dextran IV provides iron directly into circulation to support red blood cell production.

🫁 Correcting iron deficiency improves hemoglobin levels and helps reduce symptoms such as fatigue, weakness, and shortness of breath.

🫁 The nurse should monitor for allergic reactions during IV iron administration.

🫁 Iron therapy should continue until iron stores and hemoglobin levels improve.

🫁 Therefore, IV iron dextran is an appropriate treatment option for this client.

❌ Incorrect Options:

❌ Are having numbness in their hands and feet

🫁 Numbness and tingling are associated with vitamin B12 deficiency, which causes neurologic symptoms.

🫁 The client’s findings indicate iron deficiency anemia rather than B12 deficiency.

❌ Have a family member with an anemia disorder

🫁 Family history is important for inherited anemias such as sickle cell disease or thalassemia.

🫁 The client’s low MCV and low transferrin saturation indicate acquired iron deficiency.

❌ Have recently been exposed to radiation or insecticides

🫁 Radiation and chemical exposure may contribute to bone marrow suppression.

🫁 The client’s laboratory findings do not indicate aplastic anemia or toxic marrow injury.

❌ Subcutaneous vitamin B12 injections

🫁 Vitamin B12 injections are used for pernicious anemia or severe B12 deficiency.

🫁 The client’s B12 level is within the expected range and findings point toward iron deficiency.

❌ Oral folic acid

🫁 Folic acid treats folate deficiency, which causes macrocytic anemia with an increased MCV.

🫁 This client has a low MCV, indicating microcytic iron deficiency anemia.

❌ Cyclosporine

🫁 Cyclosporine is an immunosuppressant used for certain autoimmune conditions and transplant patients.

🫁 It does not treat iron deficiency anemia.

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Answer 4

Correct Answers

Hemoglobin [ decreased ]
Risk of liver cancer [ increased ]
Serum albumin [ decreased ]
Aspartate aminotransferase (AST) [ increased ]
Prothrombin time [ increased ]
Alanine aminotransferase (ALT) [ increased ]

Rationale :

🩸 Hemoglobin → Decreased ⬇️

🫁 Clients with end-stage kidney disease are at risk for anemia because damaged kidneys produce less erythropoietin, which is needed for red blood cell production.

🫁 Reduced erythropoietin results in fewer red blood cells and decreased hemoglobin levels.

🫁 Chronic illness and dialysis treatments may also contribute to blood loss and anemia.

🎗️ Risk of liver cancer → Increased ⬆️

🫁 Chronic hepatitis B infection increases the risk of developing hepatocellular carcinoma (liver cancer).

🫁 Long-term viral infection causes ongoing liver inflammation and cellular damage.

🫁 Even clients without current liver enzyme elevation can remain at increased risk.

🧪 Serum albumin → Decreased ⬇️

🫁 The liver produces albumin, which helps maintain oncotic pressure and transport substances in the blood.

🫁 Chronic liver inflammation can reduce the liver’s ability to synthesize albumin.

🫁 Low albumin levels may contribute to edema and poor nutritional status.

🧬 Aspartate aminotransferase (AST) → Increased ⬆️

🫁 AST is a liver enzyme released into the bloodstream when liver cells are injured.

🫁 Chronic hepatitis B can cause hepatocyte inflammation and damage, leading to increased AST levels.

🫁 Elevated AST indicates ongoing liver injury.

🩸 Prothrombin time (PT) → Increased ⬆️

🫁 The liver produces many clotting factors required for normal coagulation.

🫁 Liver dysfunction decreases clotting factor production, causing prolonged PT.

🫁 An increased PT indicates impaired liver synthetic function and increased bleeding risk.

🧪 Alanine aminotransferase (ALT) → Increased ⬆️

🫁 ALT is a liver-specific enzyme that rises when hepatocytes are damaged.

🫁 Hepatitis B causes inflammation and destruction of liver cells, resulting in ALT elevation.

🫁 Monitoring ALT helps evaluate the severity and progression of liver injury.

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Answer 5

Correct Answers:

Gelatin

Rationale :

🫁 Acute gastritis causes inflammation and irritation of the gastric mucosa, requiring gradual reintroduction of food after being NPO.

🫁 Gelatin is part of a clear liquid diet and is gentle on the stomach while providing a small amount of calories and hydration.

🫁 Clear liquids help assess the client’s ability to tolerate oral intake before advancing to more solid foods.

🫁 Gelatin is bland and does not contain substances that stimulate excessive gastric acid production.

🫁 The nurse should initially avoid foods and beverages that may irritate the stomach lining or worsen gastritis symptoms.

🫁 Introducing easily tolerated foods decreases the risk of nausea, vomiting, abdominal pain, and gastric discomfort.

🫁 The nurse should monitor the client for tolerance before progressing the diet as prescribed.

🫁 Therefore, gelatin is the most appropriate choice when resuming oral intake after acute gastritis.

❌ Incorrect Answers :

Lemonade

🫁 Lemonade is acidic due to its citrus content and can irritate the inflamed gastric lining.

🫁 Acidic beverages may worsen epigastric pain and gastric discomfort.

Tomato soup

🫁 Tomato soup is acidic and may increase irritation of the gastric mucosa.

🫁 It may worsen symptoms in clients recovering from gastritis.

Black coffee

🫁 Coffee can stimulate gastric acid secretion and may aggravate gastritis symptoms.

🫁 Caffeinated beverages should generally be avoided during acute gastric irritation.

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Answer 6

Correct Answers:

Frequently monitor pulse oximetry.
Frequently monitor blood glucose.
Assess for Chvostek's sign and Trousseau's sign.
Place a nasogastric tube.
Administer oxygen via nasal cannula.
Prepare to administer IV fluids.
Make the client NPO.

Rationale :

✅ Frequently monitor pulse oximetry

🫁 The client has acute pancreatitis, indicated by significantly elevated amylase and lipase levels, severe abdominal pain, vomiting, and systemic symptoms.

🫁 Pancreatitis can cause respiratory complications such as pleural effusion, atelectasis, and acute respiratory distress syndrome (ARDS).

🫁 The client’s oxygen saturation has decreased to 92%, and respiratory rate has increased to 26/min, indicating possible respiratory compromise.

🫁 Frequent pulse oximetry monitoring helps detect worsening oxygenation early.

✅ Frequently monitor blood glucose

🫁 The pancreas produces insulin, and inflammation from pancreatitis can impair pancreatic endocrine function.

🫁 Acute pancreatitis can lead to hyperglycemia due to reduced insulin production and increased stress hormones.

🫁 Monitoring glucose levels helps identify metabolic complications.

🫁 Early detection allows prompt management of abnormal glucose levels.

✅ Assess for Chvostek's sign and Trousseau's sign

🫁 The client’s calcium level is decreased (8.5 mg/dL), which can occur with acute pancreatitis.

🫁 Pancreatic inflammation can cause fat necrosis, which binds calcium and leads to hypocalcemia.

🫁 Hypocalcemia increases the risk of neuromuscular irritability.

🫁 Chvostek’s and Trousseau’s signs assess for manifestations of hypocalcemia, such as facial twitching and muscle spasms.

❌ Keep the client in a supine position

🫁 Supine positioning may worsen abdominal discomfort and increase pressure on the inflamed pancreas.

🫁 Clients with pancreatitis are often positioned with the head of bed elevated or leaning forward to reduce pain.

❌ Prepare to administer an enema

🫁 Enemas are not indicated for acute pancreatitis.

🫁 The priority interventions focus on reducing pancreatic stimulation, managing pain, and supporting fluid and respiratory status.

✅ Place a nasogastric tube

🫁 The client has severe nausea, vomiting, abdominal distention, and inability to tolerate oral intake.

🫁 A nasogastric tube may be used to decompress the stomach and reduce pancreatic stimulation.

🫁 Gastric decompression can decrease vomiting and abdominal discomfort.

✅ Administer oxygen via nasal cannula

🫁 The client has decreased oxygen saturation (92%), tachypnea, and signs of systemic illness.

🫁 Oxygen therapy improves tissue oxygenation and reduces the risk of complications from hypoxemia.

🫁 Respiratory monitoring is essential because pancreatitis can progress to respiratory failure.

✅ Prepare to administer IV fluids

🫁 Acute pancreatitis causes significant fluid shifts due to inflammation and third-spacing.

🫁 The client has signs of hypovolemia:

Blood pressure 91/55 mm Hg

Heart rate 109/min

Cool, clammy skin

🫁 IV fluids help restore circulating volume and support organ perfusion.

✅ Make the client NPO

🫁 Keeping the client nothing by mouth (NPO) reduces pancreatic stimulation and decreases secretion of digestive enzymes.

🫁 This allows the pancreas time to rest and heal during acute inflammation.

🫁 Nutrition is later advanced as symptoms improve and the client can tolerate intake.

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Answer 7

Correct Answers:

Red

Rationale :

🫁 The red triage tag indicates a client who requires immediate treatment due to life-threatening but potentially survivable injuries.

🫁 The child has a respiratory rate of 8/min, which indicates severe respiratory compromise and possible airway or breathing failure.

🫁 In mass casualty triage, breathing abnormalities are a priority because airway and breathing problems can quickly become fatal.

🫁 The child is unresponsive to verbal commands and only responds to painful stimuli, indicating a decreased level of consciousness and possible neurologic injury.

🫁 A Glasgow Coma Scale (GCS) assessment would likely indicate significant impairment requiring urgent intervention.

🫁 The child may require immediate airway support, oxygen therapy, or other lifesaving measures.

🫁 Although the injuries are severe, the child has signs of life and may benefit from rapid intervention.

🫁 Therefore, the appropriate triage classification is red (immediate priority).

❌ Incorrect Answers

Yellow

🫁 Yellow tags are assigned to clients with serious injuries who are stable enough to wait for treatment.

🫁 This child has unstable breathing and altered consciousness, requiring immediate care.

Green

🫁 Green tags are for clients with minor injuries who can walk and wait for care.

🫁 An unresponsive child with respiratory compromise does not meet green criteria.

Black

🫁 Black tags are used for clients who are deceased or have injuries incompatible with survival.

🫁 This child has signs of life and may survive with immediate intervention.

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Answer 8

Correct Answers:

Provide assistance with ambulation.

Rationale :

🫁 The cerebellum controls balance, coordination, posture, and fine motor movements, so a tumor in this area can impair the client’s ability to walk safely.

🫁 Clients with cerebellar tumors are at increased risk for ataxia (uncoordinated movements), dizziness, and falls due to impaired coordination and balance.

🫁 Assisting with ambulation is the priority because preventing injury from falls is an immediate safety concern.

🫁 The nurse should assess the client’s gait, balance, strength, and need for assistive devices before allowing independent mobility.

🫁 Providing assistance during movement promotes safety while maintaining as much independence as possible.

🫁 Fall prevention measures, such as keeping the environment free of hazards and using call assistance, are essential.

🫁 Preventing falls reduces the risk of additional injury, especially in clients with neurologic impairment.

🫁 Therefore, assisting with ambulation is the priority nursing action for a client with a cerebellar tumor.

❌ Incorrect Answers

Facilitate retention of facts by repeating instructions.

🫁 Repeating instructions may help clients with cognitive impairment but is not the priority concern with a cerebellar tumor.

🫁 Cerebellar tumors primarily affect coordination and balance rather than memory.

Place the client in a darkened room.

🫁 A darkened room is useful for clients with conditions such as migraines or photophobia.

🫁 It does not address the major safety concern of impaired coordination and fall risk.

Speak slowly and clearly.

🫁 Speaking slowly and clearly may assist clients with communication difficulties.

🫁 It does not address the immediate risk caused by cerebellar dysfunction.

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Answer 9

Correct Answers:

Ensure the door to the client's room is closed at all times.

Rationale :

🫁 Active tuberculosis requires airborne precautions because Mycobacterium tuberculosis spreads through tiny airborne droplet nuclei that can remain suspended in the air.

🫁 The client should be placed in a negative-pressure airborne infection isolation room (AIIR) with the door kept closed to prevent contaminated air from escaping.

🫁 Keeping the door closed helps maintain proper airflow and reduces the risk of transmission to healthcare workers and visitors.

🫁 Healthcare workers entering the room should wear a fit-tested N95 respirator or higher-level respiratory protection, not a standard surgical mask.

🫁 Airborne precautions are required until the client is no longer considered infectious based on clinical improvement and provider/public health guidance.

🫁 The nurse should limit unnecessary movement of the client outside the room to reduce spread of airborne organisms.

🫁 Proper environmental control is essential because TB can spread even when direct contact with respiratory secretions does not occur.

🫁 Therefore, maintaining a closed door is an appropriate action when caring for a client with active tuberculosis.

❌ Incorrect Answers :

Remain 1 m (3 feet) away from the client when providing care.

🫁 Maintaining a specific distance is used for some droplet precautions, not airborne precautions.

🫁 TB transmission occurs through airborne particles that can travel beyond 3 feet.

Apply a surgical mask before entering the client's room.

🫁 A surgical mask does not provide adequate protection against airborne TB particles.

🫁 The nurse should wear an N95 respirator before entering the room.

Place a "no visitors" sign on the client's door.

🫁 Visitors are not automatically prohibited but should follow airborne precautions.

🫁 Appropriate education and respiratory protection should be provided to visitors.

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Answer 10

Correct Answers:

Review the client's Hgb level prior to administration.

Rationale :

🫁 Epoetin alfa is an erythropoiesis-stimulating agent (ESA) that stimulates the bone marrow to produce more red blood cells.

🫁 Before administering epoetin, the nurse should review the client’s hemoglobin (Hgb) level to determine if the medication is appropriate and safe.

🫁 Epoetin is prescribed to treat anemia associated with chemotherapy by increasing red blood cell production and improving oxygen-carrying capacity.

🫁 The medication should be held and the provider notified if hemoglobin rises above the recommended target range because of the risk of complications.

🫁 Excessive increases in red blood cell production can increase blood viscosity and raise the risk of hypertension, stroke, myocardial infarction, and thromboembolic events.

🫁 Monitoring hemoglobin levels helps evaluate the effectiveness of therapy and guides dosage adjustments.

🫁 The nurse should also monitor blood pressure because epoetin can worsen hypertension.

🫁 Therefore, reviewing the client’s hemoglobin level before administration is the priority nursing action.

❌ Incorrect Answers :

Use the Z-track method when administering the medication.

🫁 The Z-track method is commonly used for irritating intramuscular medications such as iron dextran.

🫁 Epoetin is usually administered subcutaneously or intravenously, not using the Z-track technique.

Shake the vial for 30 seconds prior to withdrawing the medication.

🫁 Epoetin should not be shaken because vigorous handling can damage the protein structure of the medication.

🫁 The vial should be gently handled and inspected before administration.

Ensure the client is not taking iron supplements while on this medication.

🫁 Iron supplementation may be needed because epoetin increases red blood cell production, which requires adequate iron stores.

🫁 The nurse should monitor iron levels rather than prevent iron supplementation.

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Assessment Finding	increased	decreased
Hemoglobin
Risk of liver cancer
Serum albumin
Aspartate aminotransferase (AST)
Prothrombin time
Alanine aminotransferase (ALT)

Lab Test	1 Week Ago	Today	Reference Range
WBC	10,500/mm³	16,500/mm³	5,000 to 10,000/mm³
Serum Amylase	100 units/L	620 units/L	30 to 220 units/L
Lipase	108 units/L	300 units/L	0 to 160 units/L
Calcium	8.9 mg/dL	8.5 mg/dL	9 to 10.5 mg/dL

Rn ATI medical surgical capstone

No.

1 :
A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

2 :
A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?

3 :
A nurse is caring for a male client in the gastroenterologist's office.

Correct Answers

4 :
A nurse is caring for a male client in the outpatient dialysis clinic.

Correct Answers

5 :
A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offer the client?

6 :
A nurse in an emergency department is caring for a client.

Answer Options

7 :
A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

8 :
A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

9 :
A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?

10 :
A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?

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Rn ATI medical surgical capstone

No.

1 : A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

2 : A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?

3 : A nurse is caring for a male client in the gastroenterologist's office.

Correct Answers

4 : A nurse is caring for a male client in the outpatient dialysis clinic.

Correct Answers

5 : A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offer the client?

6 : A nurse in an emergency department is caring for a client.

Answer Options

7 : A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

8 : A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

9 : A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?

10 : A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?

1 :
A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client's bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

2 :
A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?

3 :
A nurse is caring for a male client in the gastroenterologist's office.

4 :
A nurse is caring for a male client in the outpatient dialysis clinic.

5 :
A nurse is caring for a client who has acute gastritis and is NPO. The client has a new prescription to resume oral intake. Which of the following items should the nurse offer the client?

6 :
A nurse in an emergency department is caring for a client.

7 :
A triage nurse finds a school-age child lying in the road following a school bus crash with multiple casualties. The child has a respiratory rate of 8/min, is unresponsive to verbal commands, and groans to painful stimuli. The nurse should assign the client which of the following triage tags?

8 :
A nurse is caring for a client who has a cerebellar tumor. Which of the following actions is the nurse's priority?

9 :
A nurse is caring for a client who has active tuberculosis. Which of the following actions should the nurse take?

10 :
A nurse is preparing to administer epoetin to a client who has anemia due to chemotherapy. Which of the following actions should the nurse plan to take?