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A nurse is collecting data from a client about bowel elimination. Which of the following statements by the client indicates a risk for impaired bowel elimination?
- A. I drink an average of 2,000 milliliters of water daily.
- B. I take a prescribed opioid pain medication at bedtime.
- C. I love to eat apples and black-eyed peas.
- D. I drink two hot cups of coffee each morning.
Correct Answer: B
Rationale: Opioids can cause constipation, impairing bowel elimination.
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A nurse is collecting a urine specimen for culture and sensitivity from a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Place the specimen in a clean specimen cup.
- B. Clamp the catheter tubing below the needleless port.
- C. Clamp the catheter tubing for 60 min.
- D. Remove 45 mL of urine from the catheter with a syringe.
Correct Answer: B
Rationale: Clamping below the port allows fresh urine to collect for an accurate culture.
A nurse is reinforcing teaching with a client about how to collect a stool specimen. Which of the following instructions should the nurse include?
- A. Urinate after the specimen collection.
- B. Place 1.3 cm (0.5 in) of formed stool into a culture tube.
- C. Keep the specimen in a warm area.
- D. Avoid placing toilet tissue in the bedpan after defecation.
Correct Answer: D
Rationale: Avoiding toilet tissue prevents contamination of the stool specimen.
A nurse is planning to obtain a client's oxygen saturation. Which of the following might influence the result of this test?
- A. The client has a fever.
- B. The client has an elevated hemoglobin level.
- C. The client is wearing a ring.
- D. The client is wearing nail polish.
Correct Answer: D
Rationale: Nail polish can interfere with pulse oximetry readings by absorbing light.
A nurse is caring for a client who had an indwelling urinary catheter inserted 3 days ago. Which of the following actions should the nurse take?
- A. Obtain urine from the drainage bag if a urinary specimen is required.
- B. Use a catheter securing device to hold the catheter in place.
- C. Change the catheter bag every 3 days and as needed.
- D. Position the drainage bag higher than the client's bladder.
Correct Answer: B
Rationale: A securing device prevents catheter movement and reduces infection risk.
A nurse in a provider's office is reviewing data from a client's medical record. Which of the following findings should the nurse identify as a risk factor for cardiovascular disease?
- A. BMI of 24
- B. Orthostatic hypotension
- C. Type 1 diabetes mellitus
- D. Family history of osteoporosis
Correct Answer: C
Rationale: Type 1 diabetes increases cardiovascular risk due to chronic hyperglycemia.