Question

A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?

Answer 1

Correct Answers:

Blood

Rationale :

📌A stool occult blood test (guaiac test) detects the presence of hidden (occult) blood in the stool, which may not be visible to the naked eye.

📌This is typically used to screen for gastrointestinal bleeding, polyps, or colorectal cancer.

📌The test is a routine part of cancer screening in adults over 50 or those with GI symptoms.

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Answer 2

Correct Answers:

A client who has leg strength and can cooperate with the movement

Rationale :

🔴A gait belt is used for clients who have partial mobility, especially those with sufficient leg strength and the cognitive ability to follow instructions.

🔴It provides stability during transfers and ambulation while reducing the nurse’s risk of injury.

🔴Clients who are non-weight-bearing or cognitively impaired may require additional support.

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Answer 3

Correct Answers:

A client 68 years of age who is comatose due to a traumatic brain Injury

Rationale :

🎯A comatose client is at highest risk for pressure injury development due to total immobility, reduced sensation, and inability to reposition independently.

🎯Age further increases the risk due to skin fragility and poor perfusion.

🎯These clients require regular repositioning and comprehensive skin assessments.

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Answer 4

Correct Answers:

foot drop.

Rationale :

▶Foot drop is a complication of immobility where plantar flexion contracture causes the foot to point downward, impairing gait and mobility.

▶Padded boots or foot boards are used to maintain the foot in dorsiflexion, preventing muscle shortening and joint contracture.

▶This is a key nursing intervention in unconscious clients.

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Answer 5

Correct Answers:

Greater that normal urinary volume

Rationale :

🟡Polyuria refers to increased urine output, often associated with diabetes mellitus, diuretics, or excessive fluid intake.

🟡It is defined as output greater than 2.5–3 liters in 24 hours.

🟡Accurate documentation of this condition is essential to monitor fluid balance and guide treatment.

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Answer 6

Correct Answers:

94

Rationale :

✍To calculate IV flow rate:

750mL÷8hr=93.75=94

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Answer 7

Correct Answers:

have the client fold the arms across the chest

Rationale :

📌When repositioning a client up in bed with assistance, having the client cross their arms over their chest is a vital safety and positioning strategy.

📌This technique helps ensure that the client’s arms are protected from injury during the movement, especially from pinching against side rails or dragging along the bed surface.

📌It also centralizes body weight, making the move smoother and safer for both the client and caregivers.

📌This positioning reduces the risk of musculoskeletal injury and facilitates the use of proper body mechanics by the nurse.

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Answer 8

Correct Answers:

Void and discard the urine.

Rationale :

🤞The first step in a 24-hour urine collection is to instruct the client to void and discard the initial urine specimen.

🤞This ensures that only urine collected after that point is measured, providing an accurate assessment over the full 24-hour period.

🤞The timing begins with the next void and includes all urine for the subsequent 24 hours.

🤞Failing to discard the initial void would result in inclusion of urine produced before the test started, invalidating the results.

🤞This protocol is essential for tests like creatinine clearance or hormonal assays, where precise volume and timing are critical.

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Answer 9

Correct Answers:

Contracting the gluteal muscles while holding a simple yoga pose

Rationale :

✅Isometric exercises involve the contraction of a specific muscle group without visible movement of the joint.

✅In this case, contracting the gluteal muscles while holding a yoga pose exemplifies isometric activity, as the muscles are engaged to maintain a posture without shortening or lengthening.

✅These exercises are especially beneficial for strengthening postural muscles, maintaining tone in clients who cannot perform dynamic movements, and minimizing joint strain.

✅They are commonly used in rehabilitation settings for clients with mobility restrictions or joint pain.

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Answer 10

Correct Answers:

liquid consistency.

Rationale :

💥Following an ileostomy, the stoma diverts feces from the ileum of the small intestine, bypassing the colon where water reabsorption typically occurs.

💥As a result, the stool is frequent, liquid in consistency, and rich in digestive enzymes, which can irritate the peristomal skin.

💥Nurses must educate clients on the high-output nature of ileostomies, encourage adequate fluid intake, and stress skin protection to prevent breakdown.

💥 Unlike colostomies, which may produce formed stool depending on location, ileostomies always result in watery effluent.

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RN Fundamentals Exam Nursing 100 EXAM 3

No.

1 : A nurse is caring for a client who has a prescription for a stool test for occult. The nurse understands the purpose of the test is to check the stool for which of the following substances?

2 : The nurse uses gait belts when assisting clients to ambulate. Which client would be a likely candidate for this assistive device?

3 : A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

4 : A nurse applies padded boots to maintain the foot in dorsiflexion to a client who is comatose. The nurse is protecting the client from:

5 : A client at a healthcare facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

6 : Doctor's order: 750 mL NS to infuse over 8 hours. How many mL/hr will you set the IV pump? Round to the nearest whole number.

7 : When moving a client up in bed with the assistance of another caregiver, the nurse should:

8 : A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

9 : The nurse is leading an exercise class for a group of adults aged 65 years and older. The nurse incorporates isotonic. Isometric, and isokinetic exercises into the class. Which activity is an isometric exercise?

10 : The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

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