The nurse has implemented a bladder retraining program with a 65-year-old woman after the removal of her indwelling urinary catheter. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void.
The nurse notes that the patient has 50 mL of urine remaining in her bladder after voiding. What would be the nurse's best response to this finding?
A) Perform a straight catheterization on this patient.
B) Avoid further interventions at this time, as this is an acceptable finding.
C) Place an indwelling urinary catheter.
D) Press on the patient's bladder in an attempt to encourage complete emptying.
Question 2A patient has been admitted to the neurological unit from the PACU after successful neurosurgery to remove a brain tumor. The nurse's admitting assessment reveals that the patient's gag reflex has not yet fully returned.
The nurse should recognize that this assessment finding has the potential to cause which of the following nursing diagnoses?
A) Risk for aspiration
B) Impaired spontaneous ventilation
C) Dysfunctional ventilator weaning response
D) Imbalanced nutrition: less than body requirements
Question 3A urology nurse is caring for a male patient admitted to the unit with bladder distention from prostatic hypertrophy. The health care provider orders placement of an indwelling urinary catheter.
The nurse and urologist are both unsuccessful in catheterizing this patient due to the prostatic obstruction. What approach does the nurse anticipate the health care provider using to drain the patient's bladder?
A) Insertion of a suprapubic catheter
B) Scheduling the patient immediately for surgery to relieve the bladder obstruction
C) Application of warm compresses to the perineum to assist with relaxation, which will result in the patient voiding on his own
D) Medication administration to relax the bladder muscles and attempting catheterization in 6 hours
Question 4A patient's brain tumor has been manifested by seizures that have become more frequent and severe in recent days.
The patient has been scheduled for neurosurgery but the nurse is nonetheless making changes to the patient's preoperative nursing care plan. The patient's seizures should cause the nurse to prioritize which of the following nursing diagnoses?
A) Acute pain related to seizure activity
B) Risk for injury related to seizures
C) Impaired memory related to seizure activity
D) Imbalanced nutrition: less than body requirements related to seizures
Question 5A patient's recent diagnostic workup has resulted in a diagnosis of a glioma, and a treatment plan is being promptly created by the multidisciplinary care team.
The patient's oncologist has recommended chemotherapy, which is to be administered by the intrathecal route. The nurse should understand that the rationale for choosing this administration route involves which of the following considerations?
A) The drug will bypass the bloodbrain barrier.
B) The patient will not require IV access.
C) The drug can be administered on an outpatient basis.
D) The patient will require weekly, rather than daily, drug administration.
Question 6A patient with a suspected brain tumor has been scheduled for a positron emission tomography (PET) scan. The nurse should explain to the patient that this test is being performed to assess:
A) The metabolic activity taking place in the patient's brain
B) The blood flow in the patient's brain
C) The distribution patterns of cerebrospinal fluid (CSF) in the patient's central nervous system
D) The tissue characteristics of the patient's brain
Question 7A 52-year-old patient is scheduled to undergo ileal conduit surgery and has several appropriate questions for the nurse. What would be the most relevant nursing diagnosis for this patient?
A) Self-care deficit related to the surgical procedure and creation of an ileal conduit
B) Knowledge deficit about the surgical procedure and postoperative care
C) Fear and anxiety related to the surgical procedure
D) Risk of infection related to the surgical procedure
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