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Questions 176

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Question 1 of 5

The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?

Correct Answer: A

Rationale: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.

Question 2 of 5

The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema?

Correct Answer: C

Rationale: Sodium polystyrene sulfonate (
C) removes excess potassium via the intestines, used in hyperkalemia. Other options describe unrelated procedures.

Question 3 of 5

The nurse prepares to administer medications to a client. Which of the following client data are acceptable for use as client identifiers? Select all that apply.

Correct Answer: A, B, D

Rationale: Date of birth (
A), first and last name (
B), and medical record number (
D) are reliable identifiers. Health care provider (
C) and room number (E) are not specific to the client.

Question 4 of 5

The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?

Correct Answer: A

Rationale: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.

Question 5 of 5

Which interventions does the nurse perform to promote normal rest and sleep patterns for a critically ill client? Select all that apply.

Correct Answer: A, C, D

Rationale: Dimming lights (
A), opening blinds in the morning (
C), and scheduling activities during the day (
D) promote circadian rhythms and rest. Leaving the TV on (
B) may disrupt sleep, and turning off alarms (E) compromises safety.

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