Med Surg. II Elimination

The client is diagnosed with an acute exacerbation of IBD. Which priority intervention should the nurse implement first? 1. Weigh the client daily and document in the client's chart. 2. Teach coping strategies such as dietary modifications. 3. Record the frequency, amount, and color of stools. 4. Monitor the client's oral fluid intake every shift.

3. The severity of the diarrhea helps determine the need for fluid replacement. The liquid stool should be measured as part of the total output

Which intervention is most important for the nurse to implement for the client diagnosed with rule-out renal calculi? 1. Assess the client's neurological status every two (2) hours. 2. Strain all urine and send any sediment to the laboratory. 3. Monitor the client's creatinine and BUN levels. 4. Take a 24-hour dietary recall during the client interview.

2 -Passing a renal stone may negate the need for the client to have lithotripsy or a surgical procedure. Therefore, all urine must be strained, and a stone, if found, should be sent to the laboratory to determine what caused the stone.

The male client diagnosed with CKD secondary to diabetes has been receiving dialysis for 12 years. The client is notified he will not be placed on the kidney transplant list. The client tells the nurse he will not be back for any more dialysis treatments. Which response by the nurse is most therapeutic? 1. "You cannot just quit your dialysis. This is not an option." 2. "Your angry at not being on the list, and you want to quit dialysis?" 3. "I will call your nephrologist right now so you can talk to the HCP." 4. "Make your funeral arrangements because you are going to die.

2 -Reflecting the client's feelings and re- stating them are therapeutic responses the nurse should use when addressing the client's issues.

The client is one (1) day postoperative TURP. Which task should the nurse delegate to the UAP? . Increase the irrigation fluid to clear clots from the tubing. 2. Elevate the scrotum on a towel roll for support. 3. Change the dressing on the first postoperative day. 4. Teach the client how to care for the continuous irrigation catheter

2-Elevating the scrotum on a towel for support is a task which can be delegated to the UAP.

The male client diagnosed with CKD has received the initial dose of erythropoietin, a biologic response modifier, 1 week ago. Which complaint by the client indicates the need to notify the health-care provider? 1. The client complains of flu-like symptoms. 2. The client complains of being tired all the time. 3. The client reports an elevation in his blood pressure. 4. The client reports discomfort in his legs and back.

3 -After the initial administration of erythropoietin, a client's antihyperten- sive medications may need to be adjusted. Therefore, this complaint requires notification of the HCP. Erythropoietin therapy is contraindi- cated in clients with uncontrolled hypertension.

The laboratory data reveal a calcium phosphate renal stone for a client diagnosed with renal calculi. Which discharge teaching intervention should the nurse implement? 1. Encourage the client to eat a low-purine diet and limit foods such as organ meats. 2. Explain the importance of not drinking water two (2) hours before bedtime. 3. Discuss the importance of limiting vitamin D-enriched foods. 4. Prepare the client for extracorporeal shock wave lithotripsy (ESWL

3 -Dietary changes for preventing renal stones include reducing the intake of the primary substance forming the calculi. In this case, limiting vitamin D will inhibit the absorption of calcium from the gastrointestinal tract.

The client diagnosed with renal calculi is scheduled for lithotripsy. Which postprocedure nursing task is the most appropriate to delegate to the UAP? 1. Monitor the amount, color, and consistency of urine output. 2. Teach the client about care of the indwelling Foley catheter. 3. Assist the client to the car when being discharged home. 4. Take the client's postprocedural vital signs

3 -The UAP could assist the client to the car once the discharge has been completed.

The client receiving hemodialysis is being discharged home from the dialysis center. Which instruction should the nurse teach the client? 1. Notify the HCP if oral temperature is 102˚F or greater. 2. Apply ice to the access site if it starts bleeding at home. 3. Keep fingernails short and try not to scratch the skin. 4. Encourage significant other to make decisions for the client

3 -Uremic frost, which results when the skin attempts to take over the function of the kidneys, causes itching, which can lead to scratching possibly resulting in a break in the skin.

The client diagnosed with Crohn's disease is crying and tells the nurse, "I can't take it anymore. I never know when I will get sick and end up here in the hospital." Which statement is the nurse's best response? 1. "I understand how frustrating this must be for you." 2. "You must keep thinking about the good things in your life." 3. "I can see you are very upset. I'll sit down and we can talk." 4. "Are you thinking about doing anything like committing suicide?"

3. The client is crying and is expressing feelings of powerlessness; therefore, the nurse should allow the client to talk.

Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone? 1. Dull, aching flank pain and microscopic hematuria. 2. Nausea; vomiting; pallor; and cool, clammy skin. 3. Gross hematuria and dull suprapubic pain with voiding. 4. The client will be asymptomatic.

2 -The severe flank pain associated with a stone in the ureter often causes a sympathetic response with associated nausea; vomiting; pallor; and cool, clammy skin.

The nurse is discussing kidney transplants with clients at a dialysis center. Which population is less likely to participate in organ donation? 1. Caucasian. 2. African American. 3. Asian. 4. Hispanic.

2 Many in the African American culture believe the body must be kept intact after death, and organ donation is rare among African Americans. This is also why a client of African American descent will be on a transplant waiting list longer than people of other races. This is because of tissue-typing compatibility. Remember, this does not apply to all African-Americans; every client is an individual.

The client who is postoperative TURP asks the nurse, "When will I know if I will be able to have sex after my TURP?" Which response is most appropriate by the nurse? 1. "You seem anxious about your surgery." 2. "Tell me about your fears of impotency." 3. "Potency can return in six (6) to eight (8) weeks." 4. "Did you ask your doctor about your concern?"

3 This is usually the length of time clients need to wait prior to having sexual intercourse; this is the information the client wants to know.

The client with type 2 diabetes is prescribed prednisone, a steroid, for an acute exacerbation of inflammatory bowel disease. Which intervention should the nurse discuss with the client? 1. Take this medication on an empty stomach. 2. Notify the HCP if experiencing a moon face. 3. Take the steroid medication as prescribed. 4. Notify the HCP if the blood glucose is over 160

3. This medication must be tapered off to prevent adrenal insufficiency; therefore, the client must take this medication as prescribed.

Which statement indicates discharge teaching has been effective for the client who is postoperative TURP? 1. "I will call the surgeon if I experience any difficulty urinating." 2. "I will take my Proscar daily, the same as before my surgery." 3. "I will continue restricting my oral fluid intake." 4. "I will take my pain medication routinely even if I do not hurt."

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The client returned from surgery after having a TURP and has a P 110, R 24, BP 90/40, and cool and clammy skin. Which interventions should the nurse implement? Select all that apply. 1. Assess the urine in the continuous irrigation drainage bag. 2. Decrease the irrigation fluid in the continuous irrigation catheter. 3. Lower the head of the bed while raising the foot of the bed. 4. Contact the surgeon to give an update on the client's condition. 5. Check the client's postoperative creatinine and BUN

1 - the nurse should assess the drain postop 3. the head of the bed should be lowered and the hot should be elevated to shunt blood to the central circulating system 4. The surgeon needs to be notified of the change in condition

The client had surgery to remove a kidney stone. Which laboratory assessment data warrant immediate intervention by the nurse? 1. A serum potassium level of 3.8 mEq/L. 2. A urinalysis shows microscopic hematuria. 3. A creatinine level of 0.8 mg/100 mL. 4. A white blood cell count of 14,000/mm3.

4 -The white blood cell count is elevated; normal is 5,000 to 10,000/mm3.

The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first? 1. Notify the health-care provider. 2. Assess the client for muscle weakness. 3. Request telemetry for the client. 4. Prepare to administer potassium IV.

2. Muscle weakness may be a sign of hypokalemia; hypokalemia can lead to cardiac dysrhythmias and can be life threatening. Assessment is priority for a potassium level just below normal level, which is 3.5 to 5.5 mEq/L.

The client is diagnosed with an acute exacerbation of ulcerative colitis. Which intervention should the nurse implement? 1. Provide a low-residue diet. 2. Rest the client's bowel. 3. Assess vital signs daily. 4. Administer antacids orally.

2. Whenever a client has an acute exacerbation of a gastrointestinal disorder, the first intervention is to place the bowel on rest. The client should be NPO with intravenous fluids to prevent dehydration.

The nurse is caring for the client diagnosed with chronic kidney disease (CKD) who is experiencing metabolic acidosis. Which statement best describes the scientific rationale for metabolic acidosis in this client? 1. There is an increased excretion of phosphates and organic acids, which leads to an increase in arterial blood pH. 2. A shortened life span of red blood cells because of damage secondary to dialysis treatments in turn leads to metabolic acidosis. 3. The kidney cannot excrete increased levels of acid because they cannot excrete ammonia or cannot reabsorb sodium bicarbonate. 4. An increase in nausea and vomiting causes a loss of hydrochloric acid and the respiratory system cannot compensate adequately.

3 - This is the correct scientific rationale for metabolic acidosis occurring in the client with CKD.

The nurse caring for a client diagnosed with CKD writes a client problem of "noncompliance with dietary restrictions." Which intervention should be included in the plan of care? 1. Teach the client the proper diet to eat while undergoing dialysis. 2. Refer the client and significant other to the dietitian. 3. Explain the importance of eating the proper foods. 4. Determine the reason for the client not adhering to the diet

4 -Noncompliance is a choice the client has a right to make, but the nurse should determine the reason for the noncompliance and then take appropriate actions based on the client's rationale

The client diagnosed with ulcerative colitis is prescribed a low-residue diet. Which meal selection indicates the client understands the diet teaching? 1. Grilled hamburger on a wheat bun and fried potatoes. 2. A chicken salad sandwich and lettuce and tomato salad. 3. Roast pork, white rice, and plain custard. 4. Fried fish, whole grain pasta, and fruit salad.

3. A low-residue diet is a low-fiber diet. Products made of refined flour or finely milled grains, along with roasted, baked, or broiled meats, are recommended

Which nursing diagnosis is priority for the client who has undergone a TURP? 1. Potential for sexual dysfunction. 2. Potential for an altered body image. 3. Potential for chronic infection. 4. Potential for hemorrhage.

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The client with a TURP who has a continuous irrigation catheter complains of the need to urinate. Which intervention should the nurse implement first? 1. Call the surgeon to inform the HCP of the client's complaint. 2. Administer the client a narcotic medication for pain. 3. Explain to the client this sensation happens frequently. 4. Assess the continuous irrigation catheter for patency.

4 The nurse should always assess any complaint before dismissing it as a commonly occurring problem.

The client diagnosed with IBD is prescribed sulfasalazine (Asulfidine), a sulfonamide antibiotic. Which statement best describes the rationale for administering this medication? 1. It is administered rectally to help decrease colon inflammation. 2. This medication slows gastrointestinal motility and reduces diarrhea. 3. This medication kills the bacteria causing the exacerbation. 4. It acts topically on the colon mucosa to decrease inflammation.

4. Asulfidine is poorly absorbed from the gastrointestinal tract and acts topically on the colonic mucosa to inhibit the inflammatory process

The client diagnosed with CKD has a new arteriovenous fistula in the left forearm. Which intervention should the nurse implement? 1. Teach the client to carry heavy objects with the right arm. 2. Perform all laboratory blood tests on the left arm. 3. Instruct the client to lie on the left arm during the night. 4. Discuss the importance of not performing any hand exercises.

1 -Carrying heavy objects in the left arm could cause the fistula to clot by putting undue stress on the site, so the client should carry objects with the right arm.

The client diagnosed with renal calculi is scheduled for a 24-hour urine specimen collection. Which interventions should the nurse implement? Select all that apply. 1. Check for the ordered diet and medication modifications. 2. Instruct the client to urinate, and discard this urine when starting collection. 3. Collect all urine during 24 hours and place in appropriate specimen container. 4. Insert an indwelling catheter in client after having the client empty the bladder. 5. Instruct the UAP to notify the nurse when the client urinates

1.The health-care provider may order certain foods and medications when obtaining a 24-hour urine collection to evaluate for calcium oxalate or uric acid. 2. When the collection begins, the client should completely empty the bladder and discard this urine. The test is started after the bladder is empty. 3. All urine for 24 hours should be saved and put in a container with preservative, refrigerated, or placed on ice as indi- cated. Not following specific instructions will result in an inaccurate test result.

The nurse in the dialysis center is initiating the morning dialysis run. Which client should the nurse assess first? 1. The client who has hemoglobin of 9.8 g/dL and hematocrit of 30%. 2. The client who does not have a palpable thrill or auscultated bruit. 3. The client who is complaining of being exhausted and is sleeping. 4. The client who did not take antihypertensive medication this morning

2 - This client's dialysis access is compromised and he or she should be assessed first.

The client diagnosed with ulcerative colitis has an ileostomy. Which statement indicates the client needs more teaching concerning the ileostomy? 1. "My stoma should be pink and moist." 2. "I will irrigate my ileostomy every morning." 3. "If I get a red, bumpy, itchy rash I will call my HCP." 4. "I will change my pouch if it starts leaking."

2. An ileostomy will drain liquid all the time and should not routinely be irrigated. A sigmoid colostomy may need daily irrigation to evacuate feces.

The client with a history of renal calculi calls the clinic and reports having burning on urination, chills, and an elevated temperature. Which instruction should the nurse discuss with the client? 1. Increase water intake for the next 24 hours. 2. Take two (2) Tylenol to help decrease the temperature. 3. Come to the clinic and provide a urinalysis specimen. 4. Use a sterile 4 × 4 gauze to strain the client's urine.

3 -A urinalysis can assess for hematuria, the presence of white blood cells, crystal fragments, or all three, which can determine if the client has a urinary tract infection or possibly a renal stone, with accompanying signs/symptoms of UTI.

The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse? 1. Inability to auscultate a bruit over the fistula. 2. The client's abdomen is soft, is nontender, and has bowel sounds. 3. The dialysate being removed from the client's abdomen is clear. 4. The dialysate instilled was 1,500 mL and removed was 1,500 mL.

4 -Because the client is in ESRD, fluid must be removed from the body, so the output should be more than the amount instilled. These assessment data require intervention by the nurse.

Which data support to the nurse the client's diagnosis of acute bacterial prostatitis? 1. Terminal dribbling. 2. Urinary frequency. 3. Stress incontinence. 4. Sudden fever and chills.

4 -Clients with acute bacterial prostatitis will frequently experience a sudden onset of fever and chills. Clients with chronic prostatitis have milder symptoms.

The nurse is developing a nursing care plan for the client diagnosed with CKD. Which nursing problem is priority for the client? 1. Low self-esteem. 2. Knowledge deficit. 3. Activity intolerance. 4. Excess fluid volume.

4 -Excess fluid volume is priority because of the stress placed on the heart and vessels, which could lead to heart failure, pulmonary edema, and death.

The nurse empted 2,000 mL from the drainage bag of a continuous irrigation of a client who had a transurethral resection of the prostate (TURP). The amount of irrigation in the bag hanging was 3,000 mL at the beginning of the shift. There was 1,800 mL left in the bag eight (8) hours later. What is the correct urine output at the end of the eight (8) hours? _________

800 ml

Which statement indicates the client diagnosed with calcium phosphate renal calculi understands the discharge teaching for ways to prevent future calculi formation? 1. "I should increase my fluid intake, especially in warm weather." 2. "I should eat foods containing cocoa and chocolate." 3. "I will walk about a mile every week and not exercise often." 4. "I should take one (1) vitamin a day with extra calcium."

1 -An increased fluid intake ensuring 2 to 3 L of urine a day prevents the stone-forming salts from becoming concentrated enough to precipitate.

The client diagnosed with IBD is prescribed total parental nutrition (TPN). Which intervention should the nurse implement? 1. Check the client's glucose level. 2. Administer an oral hypoglycemic. 3. Assess the peripheral intravenous site. 4. Monitor the client's oral food intake

1. TPN is high in dextrose, which is glucose; therefore, the client's blood glucose level must be monitored closely.

Which sign/symptom should the nurse expect to find in a client diagnosed with ulcerative colitis? 1. Twenty bloody stools a day. 2. Oral temperature of 102˚F. 3. Hard, rigid abdomen. 4. Urinary stress incontinence

1. The colon is ulcerated and unable to absorb water, resulting in bloody diarrhea. Ten (10) to 20 bloody diarrhea stools is the most common symptom of ulcerative colitis.

The client diagnosed with renal calculi is admitted to the medical unit. Which intervention should the nurse implement first? 1. Monitor the client's urinary output. 2. Assess the client's pain and rule out complications. 3. Increase the client's oral fluid intake. 4. Use a safety gait belt when ambulating the client.

2 -Assessment is the first part of the nursing process and is priority. The renal colic pain can be so intense it can cause a vasovagal response, with resulting hypotension and syncope.

The client is diagnosed with an acute episode of ureteral calculi. Which client problem is priority when caring for this client? 1. Fluid volume loss. 2. Knowledge deficit. 3. Impaired urinary elimination. 4. Alteration in comfort.

4 -Pain is priority. The pain can be so severe a sympathetic response may occur, causing nausea; vomiting; pallor; and cool, clammy skin.

The client with CKD is placed on a fluid restriction of 1,500 mL/day. On the 7 a.m. to 7 p.m. shift the client drank an eight (8)-ounce cup of coffee, 4 ounces of juice, 12 ounces of tea, and 2 ounces of water with medications. What amount of fluid can the 7 p.m. to 7 a.m. nurse give to the client? _____________

720 ml

The client asks, "What does an elevated PSA test mean?" On which scientific rationale should the nurse base the response? 1. An elevated PSA can result from several different causes. 2. An elevated PSA can be only from prostate cancer. 3. An elevated PSA can be diagnostic for testicular cancer. 4. An elevated PSA is the only test used to diagnose BPH

1 -An elevated PSA can be from urinary retention, BPH, prostate cancer, or prostate infarct.

Which intervention should the nurse include when preparing a teaching plan for the client with chronic prostatitis? 1. Sit in a warm sitz bath for 10 to 20 minutes several times daily. 2. Sit in the chair with the feet elevated for two (2) hours daily. 3. Drink at least 3,000 mL of oral fluids, especially tea and coffee, daily. 4. Stop broad-spectrum antibiotics as soon as the symptoms subside.

1 -The client should sit in a warm sitz bath for 10 to 20 minutes several times each day to provide comfort and assist with healing.

The client receiving dialysis is complaining of being dizzy and light-headed. Which action should the nurse implement first? 1. Place the client in the Trendelenburg position. 2. Turn off the dialysis machine immediately. 3. Bolus the client with 500 mL of normal saline. 4. Notify the health-care provider as soon as possible.

1 -The nurse should place the client's chair with the head lower than the body, which will shunt blood to the brain; this is the Trendelenburg position.

The nurse observes red urine and several large clots in the tubing of the normal saline continuous irrigation catheter for the client who is one (1) day postoperative TURP. Which intervention should the nurse implement? 1. Remove the indwelling catheter. 2. Titrate the NS irrigation to run faster. 3. Administer protamine sulfate IVP. 4. Administer vitamin K slowly.

2 -Increasing the irrigation fluid will flush out the clots and blood.

The nurse is caring for a client with a TURP. Which expected outcome indicates the client's condition is improving? 1. The client is using the maximum amount allowed by the PCA pump. 2. The client's bladder spasms are relieved by medication. 3. The client's scrotum is swollen and tender with movement. 4. The client has passed a large, hard, brown stool this morning

2 -Bladder spasms are common, but being relieved with medication indicates the condition is improving.

The client is diagnosed with Crohn's disease, also known as regional enteritis. Which statement by the client supports this diagnosis? 1. "My pain goes away when I have a bowel movement." 2. "I have bright red blood in my stool all the time." 3. "I have episodes of diarrhea and constipation." 4. "My abdomen is hard and rigid and I have a fever."

1. The terminal ileum is the most common site for regional enteritis, which causes right lower quadrant pain that is relieved by defecation.