ATI LPN
Foundations and Adult Health Nursing Test Bank
Chapter 15 Questions
Question 1 of 5
After a Foley catheter has been removed the nurse should assess the patient for:
Correct Answer: C
Rationale: While an indwelling urinary catheter is in place, the bladder loses tone and can retain urine after the removal of the catheter.
Question 2 of 5
What would be the correct explanation of catheter care?
Correct Answer: A
Rationale: The first 2 in of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift.
Question 3 of 5
During insertion of a Foley catheter the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
Correct Answer: D
Rationale: Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.
Question 4 of 5
When explaining the difference between a colostomy and an ileostomy the nurse explains which of the following about an ileostomy?
Correct Answer: B
Rationale: The ileostomy is higher in the GI tract and drains semiliquid stool. The ileostomy is very similar in appearance to the colostomy, may not be permanent, and needs a pouch.
Question 5 of 5
Before inserting a nasogastric tube what measurement should the nurse take?
Correct Answer: A
Rationale: The measurement is from the tip of the nose to the ear lobe to the xiphoid process.