PCC 1 Exam 3 Practice Questions pt.2

A nurse is caring for a client who has bowel incontinence due to the inability to reach the toilet in time. Which of the following types of incontinence is the client experiencing?

Urge incontinence

3 multiple choice options

A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?

Reflex incontinence

3 multiple choice options

A nurse is caring for a client who has a moderate vision impairment. Which of the following actions should the nurse take?

Face the client when speaking to them.

2 multiple choice options

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?

Caffeinated beverages

2 multiple choice options

A nurse is teaching a client who reports insomnia about promoting rest and sleep. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

"I will no longer have a glass of wine before bedtime."

3 multiple choice options

A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?

Macular degeneration

3 multiple choice options

A nurse is teaching a class about aromatherapy. The nurse should include that which of the following essential oils can promote sleep.

Lavender

2 multiple choice options

A nurse is assessing a client who has obstructive sleep apnea. Which of the following findings should the nurse expect?

Headache

3 multiple choice options

A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse?

Lubricates the first 2.5 to 5 cm (2 in) of the catheter.

3 multiple choice options

A nurse is teaching a newly licensed nurse about age-related changes to vision in older adult clients. Which of the following should the nurse include as an example of an expected age-related change?

Reduced depth perception.

2 multiple choice options

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse plan take?

Don sterile gloves before inserting the indwelling urinary catheter.

2 multiple choice options

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?

Take the client to the bathroom every 2 hr.

2 multiple choice options

A nurse is teaching a client about lifestyle changes to promote regular bowel elimination. Which of the following instructions should the nurse include?

Increase dietary fiber intake.

3 multiple choice options

A nurse is preparing to review discharge instructions with a client who reports having hearing loss. Which of the following actions should the nurse plan to take?

Guide the client away from background noise.

2 multiple choice options

A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first?

Perform a bladder scan.

2 multiple choice options

A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?

Withdraw 3 to 5 mL of urine from the port.

3 multiple choice options

A nurse is teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include?

Decreased ability to hear high-frequency sounds

2 multiple choice options

A nurse is teaching a class about the physiology of sleep. The nurse should include that which of the following occurs as a result of sleep?

Transfer of memory from short-term to long-term

2 multiple choice options

A nurse is assessing a client who has obstructive sleep apnea (OSA). Which of the following findings should the nurse expect?

Decreased energy

2 multiple choice options

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Measures the client's vital signs routinely

2 multiple choice options

A nurse is teaching a class about physiological changes that occur during sleep. The nurse should include that which of the following changes occur during non-rapid eye movement sleep?

Decrease in body temperature

2 multiple choice options

A nurse is teaching a class about the stages of sleep. The nurse should explain that vivid dreaming occurs during which of the following stages of sleep?

Stage 4

3 multiple choice options

A nurse is reviewing a client's electronic health record (EHR). The client was recently diagnosed with obstructive sleep apnea (OSA). Which of the following manifestations should the nurse expect?

Loud snoring followed by a snort that wakes the client

2 multiple choice options

A nurse is caring for a client who has chronic fecal incontinence and has an order for a rectal tube. Which of the following purposes should the nurse identify for its use?

To prevent skin breakdown

2 multiple choice options

A nurse is caring for a client who has urge bowel incontinence. Which of the following findings should the nurse identify as a cause of the client's incontinence?

Weak pelvic muscles

2 multiple choice options

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids.

2 multiple choice options

A nurse is caring for a client who has a new colostomy and states they are not ready to look at the stoma. The nurse encourages the client to share their feelings about the colostomy. Which of the following teaching strategies is the nurse utilizing?

Discussion

3 multiple choice options

A nurse is calculating a client's fluid output for a 12-hr period. It includes Jackson-Pratt (JP) drainage 35 mL, NG suction 120 mL, and incontinence pads weighing 240 g, 275 g, 310 g, and 270 g. The dry weight of the incontinence pads is 90 g. The nurse should record how many mL of output on the client's record? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

890 mL

A nurse is teaching a client about maintaining taste and smell. Which of the following statements should the nurse make?

"Brush your teeth twice per day."

2 multiple choice options

A nurse is planning care for a hospitalized client who has hypersomnia. Which of the following interventions should the nurse recommend to promote sleep?

Guided imagery

3 multiple choice options

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization?

A client who is in the ICU for a gastrointestinal bleed.

3 multiple choice options

A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?

Places clean linen that touched the floor in the soiled linen bag

2 multiple choice options

A nurse is assessing a client who has urinary retention. Which of the following findings should the nurse expect?

Leakage of urine

2 multiple choice options

A nurse is teaching a client who has a new colostomy. Which of the following outcomes should the nurse expect?

Report of empowerment

2 multiple choice options

A nurse is planning the discharge of a client who has sleep apnea and requires bi-level positive airway pressure (BiPAP) at night. The nurse should plan to consult with which of the following health care team members to help educate the client?

Respiratory therapist

2 multiple choice options

A nurse is providing preoperative teaching for a client who is scheduled for creation of a sigmoid colostomy. Which of the following information should the nurse include in the teaching?

Use irrigation to help establish a regular bowel pattern.

2 multiple choice options

A nurse is planning care for a client who has urinary incontinence. The nurse should plan to monitor the client for which of the following findings?

Dermatitis

2 multiple choice options

A nurse is teaching a client who is preoperative for an ileostomy. Which of the following statements should the nurse include?

"You will have a stoma placed in your right lower abdomen."

2 multiple choice options

A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

Temporary urinary retention

2 multiple choice options

A nurse is teaching a class about sleep. The nurse should include that which of the following hormones regulates the sleep-wake cycle?

Melatonin

3 multiple choice options

A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

- Perform hand hygiene. (First step to prevent infection)

- Place package on work surface. (Ensuring it is a clean, dry area at waist level)

- Open outermost flap away from self. (Prevents reaching over the sterile field)

- Open side flaps. (Maintaining sterility by only touching the outer 1-inch edge)

- Open innermost flap toward self. (The final flap opened)

Use inner surface of package as sterile field. (The sterile field is now established)

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I will clean the hearing aids with alcohol wipes."

2 multiple choice options

A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of following indications should the nurse include? (Select all that apply).

An open perineal wound

Convenience for the nursing staff or the client's family

Routine acquisition of a urine specimen

Relief of urinary retention

Measurement of residual urine after urination

An open perineal wound

Relief of urinary retention

Measurement of residual urine after urination

A nurse is caring for a client who is at risk for sensory overload. Which of the following actions should the nurse take?

Provide the client with a blindfold.

2 multiple choice options

A nurse is providing skin care for a client who has urinary incontinence. Which of the following actions should the nurse take?

Apply a barrier cream to the client's skin.

2 multiple choice options

A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

Position the client supine.

2 multiple choice options

A nurse is preparing to teach a client who has hearing loss. Which of the following actions should the nurse plan to take?

Face the client during the educational session.

2 multiple choice options

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

"I watch television until I fall asleep at night."

2 multiple choice options

A nurse is teaching a client who has bladder cancer about urinary diversion options. The nurse should inform the client that which of the following options will allow them to have some control over urinary elimination?

Kock's pouch

2 multiple choice options

A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations?

Bladder infection

2 multiple choice options

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse take?

Clean the client's skin with a pH-balanced cleanser.

2 multiple choice options

A nurse is planning to insert a female external urinary catheter for a client. Which of the following actions should the nurse plan take?

Connect the catheter to continuous wall suction.

2 multiple choice options