Question

A nurse is providing care for an elderly patient who is experiencing constipation.

What action should the nurse take?

Answer 1

Correct Answers:

Incorporate more fluids and fiber into the patient's diet.

Rationale :

✔Increasing fluids and dietary fiber is a first-line, nonpharmacological intervention to treat constipation, especially in older adults. ✔Fiber adds bulk to the stool, while fluids help soften stool consistency and promote peristalsis. ✔This approach enhances bowel function naturally and prevents dependency on laxatives.

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Answer 2

Correct Answers:

Rapid heartbeat

Rationale :

✔Tachycardia (rapid heartbeat) is an early sign of circulatory overload, reflecting the heart’s response to increased blood volume and pressure. ✔Other related symptoms may include hypertension, dyspnea, crackles, and edema. ✔Recognizing tachycardia is critical for timely fluid management and oxygen support.

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Answer 3

Correct Answers:

Muscle twitching

Rationale :

✔Muscle twitching is a neurological symptom of oxygen toxicity, often caused by prolonged high-concentration oxygen therapy. ✔Other signs may include visual disturbances, seizures, restlessness, and nausea. ✔Oxygen toxicity results from oxidative damage to lung and nervous tissue, requiring prompt adjustment of therapy.

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Answer 4

Correct Answers:

The AP instructs the patient to urinate whenever they feel the urge.

Rationale :

✔Bladder training aims to increase bladder capacity and promote scheduled voiding, not urge-based urination. ✔Encouraging voiding “whenever there’s an urge” disrupts the regimen and may reinforce urgency and incontinence. ✔The nurse should intervene to reinforce scheduled toileting routines for bladder retraining effectiveness.

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Answer 5

Correct Answers:

Metabolic alkalosis

Rationale :

✔Prolonged vomiting leads to the loss of hydrochloric acid (HCl) from the stomach, resulting in metabolic alkalosis due to increased blood pH and bicarbonate retention. ✔The nurse must monitor for signs like confusion, muscle cramps, and slow respirations, and anticipate interventions to correct fluid and electrolyte loss.

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Answer 6

Correct Answers:

I need to catheterize the stoma multiple times a day

Rationale :

✔An ileal conduit is a non-continent urinary diversion where urine drains continuously into an external pouch. ✔Catheterization is unnecessary because the stoma does not store urine; it flows directly into the pouch. ✔This statement indicates a misunderstanding of the procedure, as the patient will not need to catheterize the stoma. ✔Correct care involves pouch management, stoma hygiene, and monitoring for skin irritation.

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Answer 7

Correct Answers:

Lethargy

Rationale :

✔Respiratory acidosis occurs due to CO2 retention, leading to decreased blood pH. ✔Elevated CO2 levels cause central nervous system depression, resulting in lethargy, confusion, and headaches. ✔This symptom reflects the body's inability to compensate for the acidotic state. ✔Severe cases can progress to coma if not promptly addressed with improved ventilation.

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Answer 8

Correct Answers:

Banana.

Rationale :

✔Bananas are rich in potassium, making them an excellent dietary choice for preventing or correcting hypokalemia. ✔Potassium is critical for neuromuscular function, and deficiencies can lead to muscle weakness or arrhythmias. ✔Other potassium-rich foods include oranges, potatoes, and spinach, but bananas are often the most accessible. ✔Dietary potassium is preferred over supplements when possible, as it is better absorbed and tolerated.

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Answer 9

Correct Answers:

Don sterile gloves before inserting the indwelling urinary catheter.

Rationale :

✔Sterile technique is mandatory during catheter insertion to prevent urinary tract infections. ✔Sterile gloves maintain asepsis while handling the catheter and touching the patient's urethral meatus. ✔This step is part of a broader sterile field setup, including drapes and antiseptic cleaning. ✔Breaks in sterility increase the risk of introducing pathogens into the urinary tract.

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Answer 10

Correct Answers:

Use a sterile specimen container

Rationale :

✔A sterile container is essential for culture and sensitivity testing to avoid contamination. ✔Contaminated specimens can yield false-positive results, leading to inappropriate antibiotic therapy. ✔The specimen must be collected directly from the catheter port or midstream to ensure accuracy. ✔Proper labeling and prompt transport to the lab further ensure reliable results.

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RN Fundamental of Nursing~Exam 2 Custom~NS~117

No.

1 : A nurse is providing care for an elderly patient who is experiencing constipation.

What action should the nurse take?

2 : A nurse is gathering data on a patient who is suffering from circulatory overload.

What symptoms should the nurse anticipate?

3 : A nurse is collecting data on a patient who is experiencing oxygen toxicity.

What symptoms should the nurse anticipate?

4 : A nurse is implementing a bladder-training program for a patient.

Which of the following actions by the assistive personnel (AP) assisting with the patient's care should the nurse intervene?

5 : A nurse is caring for a patient who is experiencing nausea and vomiting.

The nurse should identify that the patient is at risk for which of the following acid-base imbalances?

6 : A nurse is educating a patient who has an ileal conduit due tobladder cancer.

Which statement from the patient suggests that further instruction is needed?

7 : A nurse is assessing a patient with respiratory acidosis.

What symptoms should the nurse anticipate?

8 : A nurse is providing dietary advice to a patient at risk for hypokalemia.

Which food should the nurse recommend as a good source of potassium?

9 : A nurse is preparing to insert an indwelling urinary catheter for a patient.

What actions should the nurse plan to take?

10 : A nurse is in the process of collecting a urine specimen for culture and sensitivity through straight catheterization.

Which step should the nurse take in this procedure?

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RN Fundamental of Nursing~Exam 2 Custom~NS~117

No.

1 : A nurse is providing care for an elderly patient who is experiencing constipation.What action should the nurse take?

2 : A nurse is gathering data on a patient who is suffering from circulatory overload.What symptoms should the nurse anticipate?

3 : A nurse is collecting data on a patient who is experiencing oxygen toxicity.What symptoms should the nurse anticipate?

4 : A nurse is implementing a bladder-training program for a patient.Which of the following actions by the assistive personnel (AP) assisting with the patient's care should the nurse intervene?

5 : A nurse is caring for a patient who is experiencing nausea and vomiting.The nurse should identify that the patient is at risk for which of the following acid-base imbalances?

6 : A nurse is educating a patient who has an ileal conduit due tobladder cancer.Which statement from the patient suggests that further instruction is needed?

7 : A nurse is assessing a patient with respiratory acidosis.What symptoms should the nurse anticipate?

8 : A nurse is providing dietary advice to a patient at risk for hypokalemia.Which food should the nurse recommend as a good source of potassium?

9 : A nurse is preparing to insert an indwelling urinary catheter for a patient.What actions should the nurse plan to take?

10 : A nurse is in the process of collecting a urine specimen for culture and sensitivity through straight catheterization.Which step should the nurse take in this procedure?

1 : A nurse is providing care for an elderly patient who is experiencing constipation.

What action should the nurse take?

2 : A nurse is gathering data on a patient who is suffering from circulatory overload.

What symptoms should the nurse anticipate?

3 : A nurse is collecting data on a patient who is experiencing oxygen toxicity.

What symptoms should the nurse anticipate?

4 : A nurse is implementing a bladder-training program for a patient.

Which of the following actions by the assistive personnel (AP) assisting with the patient's care should the nurse intervene?

5 : A nurse is caring for a patient who is experiencing nausea and vomiting.

The nurse should identify that the patient is at risk for which of the following acid-base imbalances?

6 : A nurse is educating a patient who has an ileal conduit due tobladder cancer.

Which statement from the patient suggests that further instruction is needed?

7 : A nurse is assessing a patient with respiratory acidosis.

What symptoms should the nurse anticipate?

8 : A nurse is providing dietary advice to a patient at risk for hypokalemia.

Which food should the nurse recommend as a good source of potassium?

9 : A nurse is preparing to insert an indwelling urinary catheter for a patient.

What actions should the nurse plan to take?

10 : A nurse is in the process of collecting a urine specimen for culture and sensitivity through straight catheterization.

Which step should the nurse take in this procedure?