Elimination

Which medication causes constipation?

A common side effect of iron supplements is constipation. Bisacodyl is a stool softener. Aspirin is an analgesic that does not typically cause constipation. Magnesium antacids help to decrease heartburn and do not typically cause constipation.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?

All of these interventions would be important to ensure safety in handling the client's urine and obtaining an accurate output. However, safety with handling body fluids would be a priority for the nurse to decrease risk of exposure to pathogens or blood that may be in the client's urine.

The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment?

Before palpating or percussing the abdomen, the client should empty their bladder to avoid discomfort or pressure during the examination. The only equipment used during the assessment of the abdomen is a stethoscope and the nurse's hands. Both can be warmed with the hands at the time of use. The client should be placed in a flat position with the arms at the sides. It is not necessary to obtain height and weight prior to the assessment.

The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which is the most appropriate method for the nurse to use in teaching this client?

Beginning the session with a reference to the client's actual experience will help provide a link to which the new learning can connect. Although it may be appropriate to refer the client to online resources on proper bowel health, to encourage the client to join a support group, and to consult the client's family regarding the client's history, the nurse should first engage with the client to find out the client's experience and specific issues.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Bowel function does not typically return immediately after surgery, but it can be promoted by encouraging fluid and fiber intake as appropriate to the client and his or her surgery. A medical assessment is likely unnecessary at this early postoperative stage, and an enema would likely be premature. The nurse may not independently increase the client's IV infusion, and doing so would not necessarily promote a bowel movement.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions?

Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching?

During sexual intercourse, bacteria from the perineal area may travel into the urethra and urinary bladder. The spermicide used with the diaphragm decreases the vagina's normally protective flora. The glucose in the urine acts as an excellent medium for bacteria to proliferate in the client with diabetes mellitus. Older adults are predisposed to development of urinary tract infections due to the physiologic changes associated with aging.

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of:

Fecal incontinence mainly results from physiologic or lifestyle changes that impair muscle activity and sensation of the gastrointestinal tract. Particularly in the older adult, the weakening of the intestinal walls and decreased muscle tone can lead to bowel incontinence.

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

Which statement about ostomy irrigation is true?

For some clients, regularly scheduled colostomy irrigation can be used to establish a predictable pattern of elimination. This approach allows for the use of a small covering over the colostomy between irrigations, instead of a regular appliance. Daily irrigation is necessary to assure passage of stool from an ileostomy is not warranted as ileostomy do not require daily irrigation. A contract is not necessary to sign to use the equipment. Ostomy prolapse can be delayed by resting until the prolapse recedes and twice daily irrigation is not necessary.

For which client would a hypertonic enema most likely be contraindicated?

Hypertonic solutions are contraindicated for clients with renal impairment or reduced renal clearance, because these clients have compromised ability to excrete phosphate adequately, with resulting hyperphosphatemia. Diabetes, constipation, and edema do not necessarily contraindicate the safe and effective use of a hypertonic enema.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician?

If the stoma is found to be prolapsed, the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client?

Impaired Skin Integrity related to urinary bladder infection and dehydration would be the appropriate nursing diagnosis. The nursing concern is his excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary Tract Infection is not a nursing diagnosis, rather a medical diagnosis. The impaired skin integrity is not related to functional incontinence. Urinary Incontinence is not a nursing diagnosis, rather a medical diagnosis.

The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

Which statements about suprapubic catheters is true?

Suprapubic catheters are associated with: decreased risk of contamination with organisms from fecal material; elimination of damage to the urethra; a higher rate of client satisfaction; and a lower risk of catheter-associated urinary tract infections. Suprapubic catheters are used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or gynecologic or abdominal surgery has compromised the flow of urine through the urethra. A suprapubic catheter may be preferred over indwelling urethral catheters for long-term urinary drainage in clients for whom no other alternative is possible.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question?

The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take?

The client's last bowel movement was one day earlier, so pharmacologic interventions such as suppositories or enemas are not likely warranted at this time. A change in diet may prove helpful, but the nurse's first action should be to provide a setting that is more conducive to having a bowel movement.

An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridium difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?

The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and C. difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.

A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations?

The effects of aging include the following: diminished ability of kidneys to concentrate urine, which may result in nocturia; decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination; decreased bladder contractility may lead to urine retention and stasis with increased risk of urinary tract infection; neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control of urination.

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply.

The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.

The nurse is caring for a client who had an arteriovenous (AV) graft surgically placed. The client is preparing for discharge. Which actions should the nurse teach the client to avoid? Select all that apply.

The nurse should educate the caregiver and client to avoid all actions that could impair circulation to the arm with the AV graft present. Decreasing blood flow to the affected arm could result in clotting of the AV graft. Blood pressure and venipuncture should not be attempted in the affected arm. The client should not sleep with the affected arm under the body or head as the weight/compression could decrease blood flow through the graft. Carrying heavy items can compress the graft and impair blood flow causing the graft to clot. Heavy purses or bags over the shoulder of the affected arm can decrease blood flow as well. A client with long-term hemodialysis needs should get an annual influenza vaccination. Discretion should be taken with where the vaccination is injected if prescribed intramuscular.

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?

The nurse will gather a hypertonic solution to draw water into the bowel by irritating local tissues. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem?

The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

The nurse would slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client in a supine position, rather on the left side in the Sims' position. This position aids in the client's ability to retain the solution. The nurse would not introduce the solution quickly, as this will result in the client cramping. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 20 minutes, rather 5 to 15 minutes when the urge to defecate becomes strong.

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

The risks for colorectal cancer increase after the age of 50, with a positive family history of colorectal cancer, and also with Crohn's disease. An important nursing responsibility is to teach clients about annual screening beginning at 50, encourage endoscopic exam every 5 years, or colonoscopy every 10 years for normal-risk individuals.

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum?

The tube should be inserted past the external and internal sphincters, approximately 3 in (7.5 cm). Further insertion, such as 5 in (12.5 cm), may damage intestinal mucous membrane. If the tube is inserted less than 3 in (7.5 cm), then the enema solution will not make it into the rectum but will seep out during the administration of the enema.

The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted?

The urinary bladder cannot be palpated when empty, so the client should not urinate before the nurse palpates or percusses it. During data collection, the client should be asked—before the bladder is palpated—when the last voiding occurred. The height of the edge of the bladder should be measured above the symphysis pubis. The lower abdominal wall during an urinary bladder assessment is observed for any swelling.

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask?

To determine the usual patterns of bowel elimination, the nurse asks, "How often do you move your bowels?" To determine if the client needs assistance in bowel elimination, the nurse asks, "Do you use anything to help move your bowels?" The client's social appetite, preference for hot or cold foods, or shopping arena are not questions to ask for bowel elimination.

Which client would be a candidate for total parenteral nutrition?

Total parenteral nutrition is indicated when there is interference with nutrient absorption from the gastrointestinal tract or when complete bowel rest is necessary for healing. A client with bloody diarrhea and colitis requires complete bowel rest.

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period.

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?

When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position. Prone is lying flat, especially face downward. Visualization of the rectum is acceptable but insertion of the enema is difficult. The supine position means lying horizontally with the face and torso facing up, and this is not helpful for inserting an enema as a nurse cannot visualize the rectum. The right side-lying position is used for positioning of a client, not for an enema.

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

When collecting a midstream urine specimen, the client voids a small amount, stops, and discards it; the first small amount helps to flush away organisms near the urinary meatus. The midstream urine specimen is a sterile specimen so it is not collected in the hat in the toilet bowl. The client will not need to be catheterized. It is a one-time specimen, so urine will not be collected for 24 hours.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.

Which assessment data, collected by the nurse, indicates that a client may have the nursing diagnosis of urge urinary incontinence? Select all that apply.

Losing urine when a toilet is not readily available, urinating more than eight times in a 24 hour period, and experiencing accidental loss of urine with urgency reflect urge urinary incontinence. Other answers do not reflect assessment data associated with urge urinary incontinence.

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.

The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan) and yellow are considered abnormal colors for adult stool.

The nurse is describing the role of antidiuretic hormone in the regulation of body fluids. What phenomenon takes place when antidiuretic hormone is present?

When antidiuretic hormone is present, the distal tubule of the nephron becomes more permeable to water. This causes the renal system to retain more water. A lack of antidiuretic hormone causes increased production of dilute urine. Antidiuretic hormone does not cause thirst.

The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?

Cleansing enemas are given to remove feces from the colon. Some of the reasons for administering a cleansing enema include relieving constipation or fecal impaction; preventing involuntary escape of fecal material during surgical procedures; promoting visualization of the intestinal tract by radiographic or instrument examination; and helping to establish regular bowel function during a bowel training program. Oil-retention enemas lubricate the stool and intestinal mucosa, making defecation easier. Enemas are not used for diarrhea.

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?

The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after it has been confirmed that an order for irrigation exists.

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.

A 44-year-old client is being treated for dehydration in an acute care hospital. The nurse determines that the rehydration treatment is working by assessing which values?

A balance between intake and elimination of fluids is an essential physiological need. Disruption in the water balance in the body results in either dehydration or edema. Measuring the fluid intake and output can determine the client's hydration status. A 24-hour urine output of 1500 mL is normal (range 1000 to 3000 mL/day) and indicates sufficient fluid intake to produce a normal urine output. An elevated hematocrit and urine specific gravity indicate that the client is dehydrated. An oral intake alone is not an indicator of adequate hydration.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal?

A client who is acutely confused is likely unable to manipulate a urinal effectively. Kidney stones, BPH, and previous catheterizations do not preclude the use of a urinal.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?

A standing position facilitates bladder emptying and decreases the likelihood of spillage of urine. Although female urinals exist, they are more difficult to use and are not commonly used in health care facilities. Replacing urinals every 24 hours is not necessary. A urinal should not be left in place for extended periods of time, because pressure and irritation to the client's skin can result.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

The mother of a girl 6 years of age is exasperated at her daughter's persistent enuresis. How can the nurse best respond to this mother's concern?

Enuresis typically ends between ages 6 and 8. Bedwetting at age 6 does not likely necessitate a referral to a specialist and is unlikely to be related to a pathological process. Enuresis is not noted to be more common among girls than boys.

A woman is reporting bladder urgency. It is most important to assess:

Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority?

In assessing the bladder, the nurse would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.

The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include?

Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen three to four times daily for 2 weeks to 1 month. The client should not be instructed to keep muscles contracted for at least 30 seconds, relax muscles for at least 1 minute between exercises, nor perform these exercises 10 times daily for 1 month.

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs?

Mineral, olive, or cottonseed oil is used to lubricate the stool and intestinal mucosa without distending the intestine. Water and normal saline do not have these qualities. Soap has lubricant properties but primarily acts by irritating the intestinal mucosa.

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a:

Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both.

Use of an indwelling urinary catheter leads to the loss of bladder tone. (True/False)

People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.

The health care provider requests an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position?

The Sims, or side-lying, position is especially used for clients who have limited hip mobility because it permits excellent visualization of the urinary meatus. Usually, female clients are placed in a dorsal recumbent position for catheterization, and male clients are put in a supine or semi-Fowler position.

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?

The assessment is indicative of hospital-acquired catheter infection associated with the CVC. The medical provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Checking for blood return is not indicated and access to the CVC used for hemodialysis should not be attempted without a prescription to do so from the health care provider.

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter. The health care provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Sitting the client up may aggravate the pain. The nurse should attempt to keep the client in the most comfortable position possible until a prescription is received from the health care provider.

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

The left lateral or knee to chest position is the most common position for sigmoidoscopies or colonoscopies. If the client is not able to tolerate this position, Sims' position may also be used. The right lateral, prone or semi-Fowler's positions are not routinely used for this procedure.

The nurse is caring for a client with constipation related to a small bowel obstruction. How will the nurse document this finding?

The nurse will document this finding as secondary constipation, which is a consequence of a pathologic disorder. The other answers do not correctly describe the client's condition.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply.

To correctly use the ultrasound bladder scanner, the nurse would gently palpate the client's symphysis pubis. Palpation identifies the proper location and allows for correct placement of scanner head over the client's bladder. The nurse would place a generous amount of ultrasound gel midline on the client's abdomen. The gel is necessary to conduct the ultrasound waves for an accurate reading. The nurse would aim the scanner head toward the bladder. Failure to point the scanner in this direction will give erroneous results. The nurse would adjust the scanner head to center the bladder image on the crossbars. This step is necessary to record the most accurate results.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate?

Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles and decreased activity levels contribute to constipation in older adults. Increasing dietary fiber does not decrease peristalsis. Lactose intolerance is not a developmental change in older adults. Peeling fruit does not impact bowel habits in the older adults.

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.

The nurse is engaged in collecting a urine specimen for a routine urinalysis from a client with an indwelling catheter. What nursing action has the greatest impact on the accuracy of the testing results?

When it is necessary to collect a urine specimen from a client with an indwelling catheter, the specimen should be obtained from using the special port for specimens. This practice assures aspiration of fresh urine and helps assure result accuracy. A routine urinalysis requires at least 10 ml of urine; assuring a sufficient quantity of urine. Wearing gloves protects the nurse from any contact with the specimen. A client should be placed in position that supports comfort and modesty. While all actions are accurate, appropriately accessing the specimen port has the greatest impact on the accuracy of the urinalysis.