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Measuring Intake and Output
- Which substance should the nursing assistant measure as part of a person’s intake? A. Vomitus B. Ice cream C. Tube feeding D. Intravenous (IV) fluid Rationale: Intake is the amount of fluid taken it. It includes all oral fluids and foods that melt at room temperature, such as ice cream. The nurse measures and records IV fluids and tube feedings.
- Which substance should the nursing assistant measure as part of a person’s output? A. Urine B. Sputum C. Perspiration D. Formed stool Rationale: Output is the amount of fluid lost. Output includes urine, vomitus, diarrhea, and wound drainage.
- When measuring intake and output, you may need to convert ounces (oz) to milliliters (mL). What does 1 oz equal? A. 10 mL B. 30 mL C. 45 mL D. 60 mL Rationale: To convert ounces to milliliters, remember that 1 oz equals 30 mL.
- How should you measure intake and output? A. With the graduate placed on the floor B. With the graduate held up toward the light C. In the urinal or other urine collection container D. With the graduate at eye level on a flat surface Rationale: When measuring intake or output, pour the liquid into the graduate. Measure the amount at eye level on a flat surface. Keep the graduate level.
- When should you total the amounts recorded on the intake and output (I&O) record? A. Once every 2 hours B. At the end of the shift C. As soon as you record them D. Once at the same time every day Rationale: When you measure intake and output, the amounts are recorded in the correct columns on the I&O record. Amounts are totaled at the end of the shift. The totals are recorded in the person’s chart.
Assisting with Meals
- While feeding a patient, the nurse puts the fork down on the tray and turns on the suction machine. Why might the nurse perform this action? A. The patient is tilting the head backward while drinking. B. The patient is choking. C. Food has dripped or spilled onto the patient’s clothing. D. The nurse determines that this is the wrong diet for the patient.
have trouble with many kinds of food, not just with a specific type of food.
- While feeding a patient recovering from a stroke, a nursing assistive personnel (NAP) becomes distracted and does not watch the patient swallow a bite of food. What would the NAP do to ensure that the patient safely swallowed the food? A. Give the patient a drink to wash down the food. B. Check the patient’s mouth for pocketing. C. Suction the patient’s mouth. D. Give the patient the next bite of food. Rationale: To ensure that a patient with a neurological impairment safely swallowed the food, the NAP would check the patient’s mouth for pocketing. If the patient has not swallowed the food, giving the patient a drink might further complicate the situation. Suctioning would not be necessary unless the patient were choking, gagging, or coughing. If the patient has not swallowed the food, giving the patient another bite might further complicate the situation.
- Why would the nurse want to determine if the patient is passing flatus before giving a meal? A. To ensure that the previous meal has been fully digested B. To ensure that the meal won't make the patient feel uncomfortably full C. To determine whether the GI tract is functioning D. To determine whether the patient tolerated the foods given during the previous meal Rationale: GI tract obstruction prevents the passage of flatus and may make the patient feel nauseated. To ensure that the GI tract is functioning, the nurse would want to determine whether the patient is passing flatus and free of nausea. The ability to pass flatus does not indicate that digestion has occurred. Passage of flatus occurs even in people who have been fasting. The inability to pass flatus would
indicate the possibility of GI tract obstruction, and the patient would not be allowed to eat until this possibility is ruled out. The ability to pass flatus is unrelated to food tolerance.
Screening Urine for Chemical Properties
- Testing with a urine reagent test strip shows that a patient’s urine is positive for protein, negative for glucose and blood, and has a pH of 8.2. What will the nurse do in response to these results? A. Check the medical record for further instructions from the health care provider. B. Notify the health care provider of the results of the test. C. Retain the sample, and retest it to confirm the results. D. Obtain a double-voided urine specimen. Rationale: This answer is correct. The nurse must notify the health care provider of the abnormal test results. The health care provider will need to know the results before providing further instructions. It is not appropriate to retest the same urine sample. It is not necessary to obtain a double-voided specimen unless the health care provider has ordered one.
- Which action is necessary for an accurate chemical reaction when testing urine with a reagent test strip? A. Hold the test strip in the urine for 10 seconds before completing the test. B. Compare the test strip vertically against the container. C. Wear clean treatment gloves while handling the strip. D. Keep the test strip horizontal while timing the process. Rationale: Holding the test strip horizontal will minimize the mixing of chemicals on the reagent strip, which could interfere with the chemical reaction. Holding the test strip in the urine for 10 seconds does not ensure an accurate chemical reaction when testing urine with a
voids within 40 minutes. Contamination of the sample does not pertain to the definition of a double-voided urine specimen. The time at which the patient voids is irrelevant when obtaining a double-voided urine specimen. A double-voided urine specimen is not divided for testing.
- Which action is performed initially when using a reagent strip to test the urine of a patient with type 1 diabetes for glucose? A. Apply clean treatment gloves. B. Verify the patient using two patient identifiers. C. Discard the urine after the patient voids. D. Encourage the patient to drink a glass of fluid. Rationale: This is the correct answer, because the patient’s identity must be verified before proceeding. Applying clean gloves, discarding the urine after the patient voids, and encouraging the patient to drink water or some other fluid would occur later in the process.
Providing Catheter Care
- What is the primary reason the nurse ensures that a patient’s indwelling urinary catheter drainage tubing is free of kinks? A. Kinks in the tubing cause the patient unnecessary discomfort. B. Kinks allow the drainage bag to become overly full. C. Kinks are associated with the development of urinary tract infection (UTI). D. Kinks result in scant, dark amber-colored urine. Rationale: Kinks in the drainage tubing obstruct the flow of urine into the drainage bag, which can cause UTI. Kinking of the drainage tubing interferes with proper urine drainage, perhaps making the patient uncomfortable; preventing infection, however, is more important than promoting comfort. Kinks in the drainage tubing do not result in an overly full drainage bag. In fact, they do the opposite (obstruct urine drainage into the bag), which can cause UTI. The development of
scant, dark amber-colored urine is probably a result of dehydration, not kinked tubing. Kinks in the drainage tubing obstruct the flow of urine into the drainage bag, which can cause UTI.
- The nurse has delegated measurement of a patient’s vital signs and catheter care to nursing assistive personnel (NAP). Which observation should the NAP report to the nurse immediately? A. Rectal temperature of 99.6° F B. Pulse rate of 88 beats per minute C. Redness noted on the external urethral meatus D. 200 mL of pale yellow urine in the drainage bag Rationale: Redness surrounding the external urethral meatus is a sign of impaired skin integrity and should be reported to the nurse immediately. This rectal temperature is within normal limits; a catheterized patient’s temperature should be closely monitored, however, since an elevated temperature may indicate that UTI has developed. This pulse rate is within normal limits; a catheterized patient’s pulse rate should be closely monitored, however, since tachycardia may indicate that UTI has developed. This urine output and color are within normal limits; a catheterized patient’s urine output should be monitored closely, however, to observe its characteristics (color, odor, cloudiness) and volume for signs of UTI.
- All of the following factors are known to increase the risk of urinary tract infection (UTI) except which one? A. History of fecal incontinence B. Use of an indwelling urinary catheter C. Drainage tubing is kinked D. Use of plain soap instead of an antiseptic cleanser for perineal hygiene Rationale: Use of an antiseptic cleanser has not been shown to decrease the risk of catheter-associated urinary tract infection (CAUTI). Mild soap and warm water are adequate for perineal hygiene
infection control measure, but its effect in preventing infection during catheter care is negligible. Performing hand hygiene before positioning the patient is an infection control measure, but its effect in preventing infection during catheter care is negligible. Securing the catheter to the leg (in a female patient) or abdomen (in a male patient) will prevent the catheter from pulling on the bladder and will therefore reduce the risk of CAUTI; however, it is not the most important infection control measure listed.
Obtaining a Specimen from an Indwelling Urinary
Catheter
- Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? A. Sterile technique protects the patient from microorganisms in the urine. B. Sterile technique protects the nurse from microorganisms in the urine. C. Sterile technique reduces the amount of pain caused by the procedure. D. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. Rationale: The nurse will use sterile technique to obtain a urine specimen from an indwelling urinary catheter to ensure that any microorganisms in the specimen are from the urine, not from the patient’s skin, the nurse’s hands, or the environment. Protecting the patient from microorganisms in the urine is not the goal of using sterile technique. Protecting the nurse from microorganisms in the urine is not the goal of using sterile technique. Obtaining urine from an indwelling urinary catheter does not produce pain.
- Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? A. Placing the specimen in a biohazard bag
B. Having someone take the specimen to the lab immediately C. Cleaning the outside surface of the container D. Ensuring that a stock of sterile urine collection kits is available Rationale: Having someone take the specimen to the lab immediately will help to ensure reliable results. The specimen must be delivered to the lab within 20 minutes of collection. Placing the specimen in a biohazard bag would protect others from possible contamination from the urine specimen, but it will not ensure reliable test results. Cleaning the outside surface of the container should not be necessary when collecting a sterile urine specimen through an indwelling urinary catheter. Ensuring that a stock of sterile urine collection kits is available would have no effect on the current sterile urine specimen.
- Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? A. “Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?” B. “See if the catheter is causing the patient any problems and if he is having any pain.” C. “Please get two sterile urine collection containers from the utility room.” D. “Let me know if the urine contains blood or sediment, or appears cloudy.” Rationale: This statement correctly focuses on the characteristics of urine that an NAP must report to the nurse. Patient education and pain assessment may not be delegated to NAP. A sterile container is not needed for a routine urinalysis specimen.
- Which measure may be taken to minimize the staff’s risk for infection from a urine specimen? A. Firmly securing the lid of the urine specimen container B. Using a sterile urine specimen container
Rationale: Completing this action will determine the extent of the nurse’s involvement in collecting the required sample. Gathering a Hemoccult slide and developing solution is appropriate, this would not be the initial step in preparing a fecal occult blood test. Providing the patient with a specimen hat or bedpan, performing hand hygiene and applying treatment gloves are appropriate, but this would not be the initial step in preparing a fecal occult blood test.
- The nurse has delegated to nursing assistive personnel (NAP) the task of performing fecal occult blood tests on the stool of a patient with a history of positive results. Which instruction is most relevant to performing this test in this particular patient? A. “Notify me only if the test is positive.” B. “Save the stool sample so that I can retest it if it is positive.” C. “Remind the patient that we test one section of the bowel movement.” D. “Use Gastroccult developer with Hemoccult developer.” Rationale: The nurse is likely to give NAP this instruction, because any sample from which NAP obtains a positive result must be retested. Asking the NAP to notify the nurse if the test is positive is appropriate for all patients being tested for fecal occult bleeding, but the NAP would report a negative finding as well. The sample should be taken from different sections of the stool. Hemoccult developer would be used, not Gastroccult developer.
- Which instruction to nursing assistive personnel (NAP) is most relevant to the proper performance of a fecal occult blood test using a Hemoccult slide? A. “Be sure to wear sterile gloves.” B. “Reinforce with the patient the need to use the hat.” C. “Is the patient capable of assisting with the collection?” D. “Remember to take samples from two different areas of the specimen.”
Rationale: Reminding the NAP to take samples from two different areas of the specimen is the most relevant instruction, because stool samples must be taken from two different areas and placed on the slide. Sterile gloves are not needed when testing a stool specimen for occult blood. Reinforcing with the patient the need to use the hat pertains and asking if the patient is capable of assisting with the collection pertain to obtaining the sample, not to testing the sample.
- Which statement indicates proper interpretation of the results of a positive fecal occult blood test? A. “If the sample turns blue, it is positive for bleeding.” B. “The sample turned blue after about 45 seconds.” C. “The results were positive both times the sample was tested.” D. “Because it was positive, the patient must be asked when he or she last ate red meat.” Rationale: Asking the patient when he or she last ate red meat indicates the nurse’s awareness that a positive result does not necessarily indicate gastrointestinal bleeding. The sample turning blue after 45 seconds and the results were positive both times the sample was tested indicate an understanding of proper technique, not proper interpretation of positive test results.
- Which of the following nursing actions addresses the risk for infection related to fecal occult blood testing? A. Maintaining aseptic technique while performing the test B. Performing the fecal occult blood testing in the patient’s bathroom C. Wearing clean gloves while testing D. Assessing the patient’s ability to provide an uncontaminated fecal specimen Rationale: Wearing clean gloves is the most effective way to minimize the risk for infection. Fecal occult blood testing procedure does not require aseptic technique. Although performing the fecal occult blood testing in the patient’s bathroom would not be inappropriate, other
D. Do nothing other than follow normal procedure, since menstruation will not affect the results. Rationale: The nurse would make a note on the lab slip that the patient is menstruating, to alert the lab to the possible source of any blood detected in the specimen. It is not necessary to notify the health care provider or to postpone the specimen collection. Menstrual blood in the specimen container may affect the test results, so it is necessary to notify the lab that the patient is menstruating.
- Which statement might the nurse make to nursing assistive personnel (NAP) assigned to collect a midstream urine specimen from a patient with signs of a urinary tract infection? A. “Obtain 30 to 60 mL of midstream urine.” B. “The urine has a foul odor.” C. “Teach the patient to collect the urine specimen.” D. “Be sure to maintain aseptic technique.” Rationale: The nurse would show the NAP how to keep the container sterile. The 30 to 60 mL sample is not large enough. Ninety to 120 mL of urine must be collected for a midstream urine specimen. Observation of foul odor might be reported by the NAP to the nurse, but not by the nurse to the NAP. Patient teaching may not be delegated to the NAP.
- Which statement might the nurse make to nursing assistive personnel (NAP) in order to help ensure reliable results of culture and sensitivity testing of a midstream urine specimen? A. “I’ll need a biohazard bag to put the specimen into.” B. “Please get the specimen to the lab immediately.” C. “After you replace the cap, please wipe any drops of urine from the outside of the container.” D. “We are out of specimen collection kits.”
Rationale: The nurse is likely to give this instruction to the NAP, because the specimen must be delivered to the lab immediately after collection. Doing so ensures that the reliability of the specimen is not compromised. Using a biohazard bag is proper procedure but does not improve the reliability of the culture and sensitivity testing. Wiping urine from the outside of the container reduces the risk of infection to others from accidentally handling the patient’s urine, but doing so does not improve the reliability of urine culture and sensitivity testing. The availability of specimen collection kits does not pertain to the reliability of test results.
- What is the most important action the nurse can take to ensure that a midstream urine specimen does not become contaminated? A. Wear sterile gloves to open the sterile specimen kit. B. Ensure that the patient’s perineum has been cleansed before the specimen is obtained. C. Determine if the patient has any known allergies. D. Have the patient rate his or her current pain level. Rationale: Cleansing the perineum before obtaining the midstream urine specimen helps ensure that the specimen does not become contaminated during collection. It is not necessary to wear sterile gloves to open the kit. Identifying the patient’s allergies would have no bearing on specimen contamination. Asking the patient to rate his or her pain would have no bearing on specimen contamination.
Assisting with a Urinal
- A patient with male genitalia on bed rest is permitted to stand to use the urinal. Which action would the nurse take to ensure his safety before helping the patient to a standing position? A. Determine his risk for orthostatic hypotension B. Assess his genitals for signs of impaired skin integrity C. Ask him to demonstrate proper use of a urinal
Rationale: The nurse would palpate the patient’s abdomen before assisting with a urinal in order to assess for bladder distention. The nurse would not assess the patient’s abdomen to determine bowel elimination needs before helping with use of a urinal. The nurse would not assess the patient’s abdomen for abdominal pain before helping with urinal use. The nurse would not assess the patient’s abdomen in order to determine if the patient would need help using the urinal.
- The nurse is assisting a patient with the placement of a urinal. The patient tells the nurse, “I’ll call you when I’m done.” What is the nurse’s best response? A. “All right, my name is Robin, and I’ll be right across the hall. Just call me when you’re finished.” B. “Fine. Recap the urinal, hang it on your side rail, and use your call light to let me know you’re finished.” C. “I'll check on you as soon as I get a chance.” D. “I'll be back in 15 minutes. That should be enough time for you to finish up.” Rationale: This response encourages the patient to handle the urinal appropriately after use and to rely on the call light to communicate his needs. There is no guarantee that the nurse will hear and thus respond to the patient’s call. In addition, calling across the hall may be disruptive to other patients. This response is unlikely to address the patient’s needs in a timely, appropriate manner. The patient might tire of waiting and try to get out of bed to empty the urinal himself. This response makes an assumption regarding the amount of time the patient will need to use the urinal. The patient may either feel rushed or get tired of waiting and try to get out of bed to empty the urinal himself.
- Which action promotes infection control when assisting a patient with a urinal? A. Placing a clean urinal on the overbed table B. Using a waterproof pad to protect the linen from urine spillage
C. Applying gloves before emptying and cleaning the patient’s urinal D. Asking if the patient would like to clean the genitals after using the urinal Rationale: Donning gloves before handling the urinal would promote infection control. The urinal should not be placed on the overbed table. Although using a waterproof pad may be appropriate, it does not pertain to infection control. The nurse should assist with perineal care after the patient uses the urinal, not just ask the patient if cleaning is desired.
Assisting with a Bedpan
- The nurse has delegated to nursing assistive personnel (NAP) the skill of assisting with a bedpan for a patient who has had discomfort when walking to the bathroom. Which statement made by the NAP requires the nurse’s follow-up? A. “Do you still need a stool sample for the lab?” B. “If I can get someone to help, I’ll walk her to the bathroom.” C. “The patient reports that moving is uncomfortable for her. Has she had pain medication recently?” D. “The patient told me that she’s had problems with hemorrhoids in the past.” Rationale: The NAP is not qualified to determine whether it is appropriate to ambulate the patient. The nurse has delegated the skill of assisting with a bedpan, and the NAP should carry out that responsibility as instructed. It is appropriate for the NAP to ask whether a stool sample is required. It is appropriate for the NAP to share the patient’s report of pain and to inquire about medication. Since walking is known to be painful for the patient, it stands to reason that she might be uncomfortable simply moving about in bed. It is appropriate for the NAP to share with the nurse any information pertaining to the patient’s toileting.
