Nursing

1. Chapter 29 NCLEX Questions SENSORY
1. A patient with a history of cerebrovascular accident with residual left hemiparesis and dysphagia is
hospitalized for malnutrition. Which of the following could contribute to his altered sensory
perception? Select all that apply:
1. Overstimulation caused by IV pump and bed alarms
2. Loss of self-esteem related to chronic health condition
2. An elderly patient is experiencing signs of sensory perception dysfunction related to the hospital
environment. What nursing interventions could reduce her risk factors?
1. Controlling the patient’s pain
3. A patient is identified as having disturbed sensory perception. Nursing goals for this patient include
the ability to do which of the following? Select all that apply:
1. Demonstrate understanding of contributing factors.
2. Remain free from falls during the hospitalization.
3. Demonstrate need for assistance in ADLs.
4. A patient is admitted to your skilled nursing facility with moderate confusion following a
hospitalization. Which of the following should be done first?
1. Assess current pain level.
5. You are assigned a patient who is impulsive and unsteady on her feet. Which of the following would
be appropriate to delegate to the nursing assistant that you are working with?
1. It is not appropriate to delegate care of this patient to a nursing assistant.
6. A nurse is teaching an 80-year-old patient who was recently admitted with urinary tract infection
(UTI) about the effects of the new medications that are prescribed. After the third medication, the
patient acts confused and repeatedly asks the nurse to repeat instructions every few minutes. How
will the nurse chart the patient’s reaction?
1. “The patient is a new admit and will be needing more teaching about medication.”
7. The nurse is administering the routine antidiabetic medications at the beginning of the shift. The
patient asks for help in ordering a breakfast tray. What will the nurse do to help the patient?
1. Ask if the patient needs help in reading the menu.
Chapter 34 URINARY ELIMINATION
1. Selective reabsorption of water and ions occurs in which part of the nephron?
1. Tubules
2. Micturition occurs when:
1. Pelvic muscles relax and abdominal muscles contract.
3. Your patient is diagnosed with a UTI. Which urinary signs would best support this diagnosis?
1. Cloudy urine
4. Which patient condition would you expect to have decreased urinary output (volume)?
1. A postoperative patient in recovery room
5. Which urinary output represents abnormal findings?
1. Incontinence in an elderly female patient
6. Which of the following are expected findings?
1. Polyuria in a patient with poorly managed diabetes
2. Anuria in a patient with end-stage renal disease
3. Hematuria in a patient with a UTI
4. Urinary retention in patient with thoracic spinal cord injury
5. All of the above

2. 7. Your patient had a urinary catheter removed at 06:00 and has not voided. It is now 14:00. What
would you do first?
1. Assess sensations of fullness and distention.
8. Your assessment of an elderly female indicates the following: alert and oriented, ambulates
independently, reports urinary frequency, and incontinence with coughing. Which nursing
diagnosis best describes this patient’s condition?
1. Stress incontinence
9. You are working with an elderly patient with altered mental status and urinary incontinence.
What nursing interventions would be most appropriate? (Select all that apply):
1. Encourage patient to avoid smoking and drinking coffee.
2. Schedule toileting at least every 2 hours.
10. Indwelling urinary catheters are not indicated in which of the following patient conditions?
1. Impaired mobility
11. A patient had an indwelling catheter removed at 04:00 by the night shift nurse. At 09:00, the
day shift nurse notices that the patient has voided 155 mL. What will the nurse do next?
1. Record the findings in the patient’s chart.
12. The nurse is caring for a patient who has congestive heart failure and is taking a diuretic
medication. What will the nurse do to prevent the patient from injuries?
1. Remind the patient to dangle feet prior to getting up.
Chapter 36 SLEEP
1. A patient seen at an annual physical is observed to be irritable and unable to concentrate. When
questioned about his behavior, he attributes it to working two full-time jobs. What nursing
diagnosis would be most appropriate?
1. Sleep deprivation
2. A postoperative patient with a history of OSA is admitted to your unit. Which assessment finding
would you be most concerned about?
1. Patient difficult to arouse
3. A patient complains about inability to sleep in the hospital. Which of the following nursing
interventions would be most beneficial to do first?
1. Complete a pain assessment
4. Which of the following factors influence sleep and rest needs? Select all that apply.
1. Developmental stage
5. Normal circadian rhythms would be seen in which of the following individuals?
1. A 1-year-old pediatric patient
6. What is the most accurate description of sleep?
1. Altered consciousness with relative inactivity
7. Which hormone is produced during sleep?
1. Melatonin
Chapter 35 BOWEL ELIMINATION

3. 1. Which of the following bowel habits are abnormal?
1. Elderly adult with fecal incontinence
2. You are assessing factors related to constipation in your postoperative patient. Which of the
following could contribute to constipation? Select all that apply:
1. Opioid analgesics
2. Decreased mobility
3. Fear of pain
4. Supine position
5. Lack of privacy
3. This morning, your adult patient reports new onset of frequent diarrhea with mucus and a foul
odor. Which medication class would you suspect as being related?
1. Antibiotic
4. Which of the following findings are abnormal?
1. Positive FOBT guaiac
5. You perform a FOBT guaiac test on a stool sample from a patient with a history of
gastrointestinal bleeding. Which step would you do first after applying stool to the Hemoccult
slide?
1. Wait 3 to 5 minutes.
6. You are caring for a female patient who is concerned that she has not had a bowel movement
since yesterday and hasn’t taken her laxative. You assess her abdomen and find bowel tones
throughout all quadrants, reports of flatus, and that abdomen is soft and not distended or
tender. Which nursing diagnosis would be most appropriate for this patient?
1. Perceived constipation
7. You determine that your patient is at risk for constipation related to his postoperative status.
What interventions can you provide to reduce this risk?
1. Promote ambulation as tolerated.
8. You have just placed a nasogastric tube for gastric decompression secondary to a paralytic ileus.
What is the first thing that you need to do?
1. Ensure accurate placement.
2. You are providing discharge teaching to a patient with a colostomy. You include the
following instructions about applying the colostomy wafer and bag. Select all that apply:
3. Ensure that the opening in the wafer is tight to the stoma to prevent leakage.
4. Leakage of colostomy contents to the surrounding area may lead to skin breakdown.
5. Some bleeding may occur because stoma tissues are fragile.
9. The wound nurse is visiting a patient with a new colostomy for a final appointment prior to
discharge. Which patient statements would be most concerning?
1. “I can’t stand to even look at my stomach!”
10. A patient who regularly walks around the park and includes fiber consistently in his or her diet
reports experiencing constipation. How will the nurse start the teaching?
1. Ask the patient about the amount of fluid intake.
11. A patient is refusing to use a bedpan and reports inability to defecate while using a bedpan in the
past. What will the nurse teach the patient?
1. Sit up as much as possible to produce a downward pressure.