PrepU-Elimination
Which of the following is a function of the stomach? Select all that apply.
* Food storage • Secretion of digestive fluids • Propels partially digested food into small intestine
. A nurse is calculating the body mass index (BMI) of a 35-year-old male patient who is extremely obese. The patient's height is 5′6″ and his current weight is 325 pounds. What would the nurse document as his BMI?
52.4
Which of the following is the primary function of the small intestine?
Absorption
A client has had abdominal surgery and in 72 hours develops abdominal distention and absence of bowel sounds with pain. The nurse suspects the client has
Paralytic ileus An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention.
Barium
UGI TEST
A nurse is caring for a patient who is taking phenazopyridine (Pyridium, a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish-red today; is there something wrong with me?" What would be the nurse's best response?
This is a normal finding when taking phenazopyridine."
A patient is to undergo a TURP for BPH. Which of the following is accurate with regard to a TURP?
Urethral strictures are more frequent for TURP than with nontransurethral procedures.
anuria
absence of urine
Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
auscultation of bowel sounds
hematuria
blood in urine
polyuria
excessive urine
A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient?
kegels
dysuria
painful urination
diuresis
promotion of increased urine output
Blood shed in sufficient quantities into the upper GI tract, produces which color of stool?
tarry black
A nurse caring for a patient's hemodialysis access documents the following: "5/10/15 0930 Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider?
warm to touch
Nitrofurantoin, 75 mg four times per day, has been prescribed for a client with a lower urinary tract infection. The medication comes in an oral suspension of 25 mg/5 mL. How many milliliters should the nurse administer for each dose? Record your answer using a whole number.
15
A nurse is teaching a new mother about intussusception. Which signs and symptoms should the nurse include?
Abdominal distension and vomiting Intussusception occurs when a portion of the bowel slides into the next, like the pieces of a telescope. When this occurs it can create a blockage in the bowel, with the walls of the intestines pressing against one another. This leads to abdominal swelling, inflammation, and decreased blood flow to the part of the intestines involved. Additional symptoms include vomiting, passing of stools mixed with blood and mucus, and grunting due to pain.
To assess subjective data related to a client's elimination pattern, the nurse
Asks the client about changes in elimination patterns Focus the interview on the client's normal urinary and bowel patterns, noting any recent changes.
The nurse is caring for a patient following a cystoscopic examination. Following the procedure, the nurse informs the patient that which of the following may occur?
Blood-tinged urine
A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output?
Decreased and highly concentrated
A nurse who has diagnosed a patient as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?
Distended neck veins 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 of the following accounts for the majority of ureteral injuries?
Gunshot wounds Gunshot wounds account for 95% of ureteral injuries, which may range from contusions to complete transection. Unintentional injury to the ureter may occur during gynecologic or urologic surgery. Knife wounds and sports injuries do not account for the majority of ureteral injuries.
After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding?
Having the patient ignore the urge to void until her bladder is full.
The nurse in the ED is admitting a patient with bloody stools. The nurse documents this finding as being which of the following?
Hematochezia
The nurse is reviewing the laboratory data for a young client in acute kidney failure and notes an elevated serum potassium level. What is the priority assessment action for the nurse based on the laboratory data?
Institute telemetry monitoring.
Which of the following is the most common symptom of a polyp?
Rectal bleeding The most common symptom is rectal bleeding. Lower abdominal pain may also occur. Diarrhea and anorexia are clinical manifestations of ulcerative colitis.
A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises?
Stop the flow of urine while urinating. Explanation: By stopping urine flow during urination, the pelvic floor muscles are contracted. Tightening the leg or stomach muscles doesn't contract the pubococcygeus muscle. Pelvic squats don't tighten the pelvic floor muscles
The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure?
The male urethra is more vulnerable to injury during insertion.
Which of the following indicates an overdose of lactulose?
Watery diarrhea
oliguria
reduced urine
After undergoing a barium enema, which finding indicates that the infant has adequately evacuated the barium?
stools that progress from clay-colored to brown
The client will have an abdominal hysterectomy tomorrow. Which information will be most important for the nurse to give to the client prior to admission to the hospital?
what she can eat and drink before admission It is a priority that the client knows she will not be able to eat or drink for 8 hours before admission. A client who consumes food and fluid before receiving a general anesthetic is at risk for aspiration, which can lead to aspiration pneumonia, respiratory arrest, and even death. The clothing she should wear to the hospital and the type of medication she will receive are important, but not the priority. Information on exercise and resumption of normal activities can be included in the discharge teaching.
A client comes to the clinic reporting urinary symptoms. Which statement would most likely alert the nurse to suspect benign prostatic hyperplasia (BPH)?
"I've had trouble getting started when I urinate, often straining to do so." Symptoms that might alert the nurse to BPH include difficulty initiating urination and abdominal straining with urination. Although fever, urinary frequency, nocturia, pelvic pain, nausea, vomiting, and fatigue may be noted, they also may suggest other conditions such as urinary tract infection. Fever, nausea, vomiting, and fatigue are general symptoms that can accompany many conditions.
The client is taking continuous-release oxycodone (Oxycontin) for chronic pain and now reports constipation. The first question the nurse asks is
"When was your last bowel movement?" Constipation is a common side effect of opioids. The nurse needs to assess the situation first before intervening. Asking about date of last bowel movement is most important. Once the history of constipation is completed, it would then be appropriate for the nurse to ask about effectiveness of past interventions and begin teaching about interventions, such as increasing fluids and fiber.
A nurse is helping an overweight female patient to devise a meal plan to lose 2 pounds per week. How many calories would the patient need to delete per day in order to accomplish this goal?
1000 calories
Which of the following is the primary function of the small intestine?
Absorption Absorption is the primary function of the small intestine. Digestion occurs in the stomach. Peristalsis occurs in the colon. The duodenum secretes enzymes.
Which of the following is a factor that alters urinary elimination patterns in the older adult?
Decreased muscle tone Older adults typically have decreased muscle tone related to urinary elimination. Increased residual volume, decreased bladder capacity, and sedentary lifestyle are other factors that alter urinary elimination patterns in the older adult.
A female patient presents to the health clinical for a routine physical examination. The nurse observes that the patient's urine is bright yellow in color. Which of the following questions is most appropriate for the nurse to ask the patient?
Do you take multiple vitamin preparations?" Urine that is bright yellow is an anticipated abnormal finding in the patient taking a multiple vitamin preparation. Urine that is orange may be caused by intake of Dilantin or other medications. Orange- to amber-colored urine may also indicate concentrated urine due to dehydration or fever. Urine that is pink to red may indicate lower urinary tract bleeding. Yellow to milky white urine may indicate infection, pyuria, or, in the female patient, the use of vaginal creams.
Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces.
False
Which type of incontinency refers to the involuntary loss of urine due to medications?
Iatrogenic
Which of the following nursing diagnoses would be most appropriate for a patient with a body mass index (BMI) of 18?
Imbalanced Nutrition: Less Than Body Requirements - A patient with a body mass index (BMI) of 18 is considered underweight, therefore a diagnosis of Imbalanced Nutrition: Less than Body Requirements is appropriate
The nurse is developing a plan of care for an older child who had a colostomy surgically created 6 months ago. Which nursing diagnosis is a priority for this client?
Impaired body image related to the colostomy
Which of the following medications causes constipation?
Iron supplements A common side effect of iron supplements is constipation. Dulcolax 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 client had an open cholecystectomy (gall bladder 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?
Monitor the client closely and promote fluid intake. Explanation: 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.
Which of the following statements should be included in the nurse's teaching plan for older adults regarding urinary elimination?
Nocturia and urinary retention is more common in older adults Nocturia and urinary retention are common in older adults.
A patient who is moved to a hospital bed following throat surgery is ordered to receive continuous tube feedings through a small-bore nasogastric tube. Following placement of the tube, which nursing action would the nurse initiate to ensure correct placement of the tube?
Order radiographic examination of the tube.
Patients with irritable bowel disease (IBS) are at significantly increased risk for which of the following?
Osteoporosis Patients with IBD also have a significantly increased risk of osteoporotic fractures due to decreased bone mineral density. Patients are not at increased risk of DVT, hypotension, or pneumonia
A client with colorectal cancer is complaining to the nurse of constipation. Which of the following signs or symptoms accompany constipation?
Pain on defecation Explanation: Constipation is accompanied by various signs and symptoms, such as pain on defecation, abdominal distention, and changes in the characteristics of stool, such as oozing liquid stool or hard, small stool. When a person has constipation, he or she does not complain of an increased but a decreased frequency of bowel movements. Clients complain of abdominal fullness or bloating and an inability to pass stool, not urine.
After a laminectomy, a client has a palpable bladder and reports lower abdominal discomfort with voiding 60 to 80 mL of urine every 4 hours. The vital signs are BP 110/88 mm Hg, HR 86 bpm, and RR of 20 breaths/min. What is the best nursing intervention?
Perform a bladder scan, and obtain an order for urinary catheterization. The client has overflow retention. A catheter relieves the discomfort by draining urine from the bladder. Permitting further distension could injure the bladder. Although an analgesic may relieve the discomfort, it will not resolve the primary cause. Nurses' self regulation practice can perform a bladder scan without an order. Other answers are incorrect because the client may have neurologic impairment and decreased sensation for voiding.
Following ingestion of carrots or beets, the nurse would expect which alteration in stool color?
Red Correct Explanation: Carrots or beets will tend to change the stool color to red. Black stools are associated with iron, licorice, and charcoal. Senna is associated with yellow stools. A milky white stool is associated with administration of barium.
A client with AIDS is admitted to the hospital with severe diarrhea and dehydration. The physician suspects an infection with Cryptosporidium. What type of specimen should be collected to confirm this diagnosis?
Stool specimen for ova and parasites A stool specimen for ova and parasites will give a definitive diagnosis. The organism is spread by the fecal-oral route from contaminated water, food, or human or animal waste. Those infected can lose from 10 to 20 L of fluid per day. Losing this magnitude of fluid quickly leads to dehydration and electrolyte imbalances
A nurse is feeding an elderly patient who has dementia. Which intervention should the nurse perform to facilitate this process?
Stroke the underside of the patient's chin to promote swallowing. - To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands.
A patient who has undergone colostomy surgery is experiencing constipation. Which of the following interventions should a nurse consider for such a patient?
Suggest fluid intake of at least 2 L per day For constipation the nurse should suggest a fluid intake of at least 2L per day. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the patient to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the patient to keep a record of food intake in case of diarrhea because this helps identify specific foods that irritate the GI tract
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
Take a stool softener such as docusate sodium daily. Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.
What is the rationale for having the client void before surgery?
To prevent bladder distention Explanation: Having the client void before surgery will assist in the prevention of bladder distention during or after the procedure
James Roth, a 63-year-old accountant, is a client on the hospital unit where you practice nursing. Mr. Roth has developed urinary incontinence and is beginning bladder training to regain control over his urine elimination. Why is the catheter being clamped and unclamped?
To promote normal bladder function The clamping and unclamping of the catheter begins to reestablish normal bladder function and capacity.
When the bladder contains 300 mL or more of urine, this is referred to as
functional capacity A marked sense of fullness and discomfort with a strong desire to void usually occurs when the bladder contains 350 mL or more of urine, referred to as the "functional capacity." Anuria is a total urine output of less than 50 mL in 24 hours. Specific gravity reflects the weight of particles dissolved in the urine. Renal clearance refers to the ability of the kidneys to clear solutes from the plasma
A teenage girl has been diagnosed with a urinary tract infection. The nurse recognizes the need for teaching when the teenager states:
"I can drink coffee." Drinking coffee and other beverages that contain caffeine can irritate the bladder and should be avoided. Bubble baths, bath oils and hot tubs can irritate the urethra and perineal area. Drinking plenty of water will keep urine flushed through the bladder. Cranberry juice helps to acidify the urine.
A nurse is teaching an elderly client about developing good bowel habits. Which statement by the client indicates to the nurse that additional teaching is required?
"I need to use laxatives regularly to prevent constipation." The client requires more teaching if he states that he'll use laxatives regularly to prevent constipation. The nurse should teach this client to gradually eliminate the use of laxatives because using laxatives to promote regular bowel movements may have the opposite effect. A high-fiber diet, ample amounts of fluids, and regular exercise promote good bowel health
. A nurse performs presurgical assessments of patients in an ambulatory care center. Which patient would the nurse report to the surgeon as possibly needing surgery to be postponed?
A 43-year-old patient who takes ginko bilboa and an aspirin daily - A patient taking gingko biloba (an herbal), aspirin, and vitamin E (dietary supplement) may have to have surgery postponed due to an increased risk for excessive bleeding, because each of these substances have anticoagulant properties
A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination related to maturational enuresis. Based on this diagnosis, for which patient is the nurse caring?
A child older than 4 years of age who has involuntary urination
A nurse is evaluating patients to determine their need for total parenteral nutrition (TPN). Which patients would be the best candidates for this type of nutritional support? Select all that apply.
A patient with irritable bowel syndrome who has intractable diarrhea -A patient with celiac disease not absorbing nutrients from the GI tract -A patient with burns who has not been able to eat adequately for 5 days
The nurse is conducting discharge teaching for a patient who was admitted with a kidney stone. The nurse includes which of the following as a measure to prevent additional kidney stones?
Avoid drinking tea. The nurse should teach the patient to avoid tea and other oxalate-containing foods, such as spinach, strawberries, rhubarb, peanuts, and wheat bran. The patient should restrict protein intake to 60 g/day and should drink two glasses of water at bedtime. Low-calcium diets are generally not recommended.
The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?
Cola-colored urine Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria.
Which of the following is an age-related change that may affect diabetes and its management?
Decreased renal function Decreased renal function affects the management of diabetes. Other age-related changes that may affect diabetes and its management include hypertension, decreased bowel motility, and decreased thirst.
A client who is blind is admitted for treatment of a small bowel obstruction and has been vomitting for days. Which nursing diagnosis takes highest priority for this client?
Deficient fluid volume Although the client's disability should be considered in the course of assessment and delivery of health and nursing care, it should not become the overriding focus or exclusive focus of the assessment or the care that the client receives. Because the client has been vomitting for days, he is most likely dehydrated; therefore, deficient fluid volume takes highest priority. A sensory deficit such as blindness puts the client at risk for injury from the environment; however, a ptoential problem doesn't take highest priority.
The nurse is inserting a urinary catheter into a female patient and has begun to inflate the balloon, an action that has caused the patient to wince and cry out in pain. Consequently, the nurse should do which of the following?
Deflate the balloon, insert the catheter further, and slowly attempt reinflation. If the patient complains of pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the patient's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 1/2 to 1 (1.22.4 cm), and slowly attempt to inflate the balloon again. Reattempting inflation in the same location or after withdrawing slightly could cause trauma to the patient's urethra. It is not necessary to utilize a smaller gauge catheter.
The adult client in good health has just started a walking exercise program and tells the nurse that he has to urinate more often and asks why this is happening. What would be the nurse's best response?
Exercise improves circulation to the kidneys so you may urinate more often.? Exercise has many effects on the major body systems. Kidney function is affected where blood flow to the kidneys is increased resulting in improved circulation to the kidneys and excretion of body wastes; urine output would be increased. Although it is true that increased urination is a response to increased activity and exercise, telling the client that this is a common response to exercise does not address the client?s question. Urinary tract infections can be caused by urinary stasis which is an effect of immobility, not exercise, would have on the kidneys. The development of kidney stones is an effect immobility would have on the kidneys in which there is decreased urinary volume and increased urinary calcium.
You are attempting to insert a urinary catheter into a female patient's bladder and realize the catheter has been inserted into the vagina. Which of the following actions is most appropriate?
Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
A client has had abdominal surgery and in 72 hours develops abdominal distention and absence of bowel sounds with pain. The nurse suspects the client has
Paralytic ileus Explanation: An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention.
A nurse is administering a tube feeding for a patient who is post bowel surgery. When attempting to aspirate the contents, the nurse notes that the tube is clogged. What would be the nurse's next action following this assessment?
Use warm water and gentle pressure to remove the clog. - In order to remove a clog in a feeding tube, the nurse should try using warm water and gentle to unclog it. A stylet should never be used to unclog a tube, and cola and meat tenderizers have not been shown effective in removing clogs. The nurse should first attempt to remove the clog, and if unsuccessful, the tube should be replaced.
The health care provider prescribes a high fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?
Whole wheat spaghetti and broccoli To promote bowel elimination, consume 20 to 35 g of fiber daily. Foods high in fiber include fresh fruits and vegetables, bran, and whole grains. Cream of Wheat is refined cereal and fiber has been removed from apples because of cooking. Other foods low in fiber include soda crackers, chicken noodle soup, tea, and flavored water.
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Which information is least important for the evaluation process?
age
The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?
an orange, raisin bran and milk, and wheat toast with butter Explanation: High-fiber foods provide bulk and decrease water absorption in the bowel. Whole grains and fruits (not juices, which often are strained) are recommended. Of all the breakfast options listed, the one that includes an orange, raisin bran, and wheat toast is highest in fiber and most likely to enhance bowel elimination. Proteins, white bread, processed foods, and liquids contain very little fiber.
Which assessment should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
auscultation of bowel sounds Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specific gravity provides information about fluid and electrolyte status. The first stool and the amount of gastric output provide information about the return of gastric function.
While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal birth, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the health care provider (HCP) because these findings indicate which problem?
biliary atresia Jaundice that persists past the third or fourth day of life and pale, light stools are associated with biliary atresia. Alkaline phosphatase levels will also be elevated. Surgical intervention is necessary to remove the blockage. Rh isoimmunization and ABO incompatibility are associated with neonatal anemia as the red blood cells are hemolyzed by the antibodies. Esophageal varices are associated with cirrhosis of the liver and large amounts of bleeding when the vessels rupture. The child with esophageal varices will exhibit manifestations of anemia such as pallor and may experience hemorrhage and shock.
A nurse is assessing a patient the first day after colon surgery. Based on knowledge of the effects of anesthesia and manipulation of the bowel during surgery, what focused assessment will be included?
bowel sounds Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, which may cause a condition termed paralytic ileus. This temporary stoppage normally lasts 24 to 48 hours. Nurses will listen for bowel sounds as part of regular assessments.
The nurse determines that interventions for decreasing fluid retention have been effective when the nurse makes which assessment in child with nephrotic syndrome?
decreased abdominal girth Explanation: Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
increase the frequency of the catheterizations.
A client is prescribed methadone 10 mg three times a day for neuralgia following chemotherapy treatment. The client reports that he is experiencing constipation and asks the nurse for information about preventing constipation. The nurse recommends
increasing the amount of bran and fresh fruits and vegetables Constipation is a common problem with the use of opioid medications, such as methadone. Activities to prevent constipation include increasing bran and fresh fruits and vegetables in the diet. The client should ingest 8 to 10 glasses of fluids per day. Milk of magnesia may be used if no bowel movement is produced in 3 days. Milk of magnesia is not to be used daily. A glycerin suppository, not bisacodyl, may be used to make the bowel movement less painful.
Bladder retraining following removal of an indwelling catheter begins with
instructing the patient to follow a 2 to 3 hour timed voiding schedule. Immediately after the removal of the indwelling catheter, the patient is placed on a timed voiding schedule, usually 2 to 3 hours. At the given time interval, the patient is instructed to void. Immediate voiding is not usually encouraged. The patient is commonly placed on a timed voiding schedule, usually within 2 to 3 hours. Immediately after the removal of the indwelling catheter, the patient is placed on a timed voiding schedule, usually 2 to 3 hours, not 6 hours. If bladder ultrasound scanning shows 100 mL or more of urine remaining in the bladder after voiding, straight catheterization may be performed for complete bladder emptying.
After undergoing a barium enema, which finding indicates that the infant has adequately evacuated the barium?
stools that progress from clay-colored to brown Correct Explanation: The presence of barium produces white or clay-colored stools. A change in stool color from clay-colored to normal brown is an indication that the barium has been evacuated. Presence or absence of a fecal mass does not give definitive information about the passage or retention of barium. Bowel sounds of 30 per minute suggest normal functioning but do not necessarily indicate passage of barium. A stool guaiac test is done to determine the presence of occult blood not barium.
A client has stress incontinence. Which data from the client's history contributes to the client's incontinence?
the client's history of three full-term pregnancies The history of three pregnancies is most likely the cause of the client's current episodes of stress incontinence. The client's fluid intake, age, or history of swimming would not create an increase in intra-abdominal pressure.
The nurse is providing preoperative instructions to a client who is having a transurethral resection of the prostate. The nurse should tell the client:
"Expect blood in your urine in the first couple of days following the procedure." Transurethral resection of the prostate (TURP) is a common surgical procedure used to treat male clients with benign prostate enlargement. The surgery commonly results in blood from the surgery in the urine for the first few days, and the client should not be concerned; the urine will become clear within 2 to 3 days. Central venous access is not expected for this type of surgery. Peripheral IV access can be expected. Clients are instructed to anticipate hospitalization for 1 to 3 days. Because the procedure is performed transurethrally (via the urethra), there is no outward incision.
Which of the following statements, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?
"I can have a hamburger and French fries as soon as I wake up." Oral fluid and food may be withheld until intestinal motility resumes.
A 7-month-old female infant is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. When obtaining the infant's initial health history from the parents, which statement made by the mother would be most important?
"She gets constipated often." Infants with Hirschsprung's disease typically have a history of abdominal distention, constipation, periodic diarrhea (when liquid stool leaks around the semiobstructed colon), and failure to thrive. Having an occasional cold is not unusual for an infant and is not related to Hirschsprung's disease. Spitting up once in a while is not unusual for an infant. A rectal temperature of 99.4° F (37.4° C) would be considered normal.
A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?
All four abdominal quadrants auscultated. Inaudible bowel sounds." Correct In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. The other responses are incorrect documentation.
Which type of medication may be used in the treatment of a patient with incontinence to inhibit contraction of the bladder?
Anticholinergic agent Anticholinergic agents are considered first-line medications for urge incontinence. Estrogen decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. Tricyclic antidepressants decrease bladder contractions as well as increase bladder neck resistance. Stress incontinence may be treated using pseudoephedrine and phenylpropanolamine, ingredients found in over-the-counter decongestants.
A client with Crohn's disease is scheduled for a barium enema. What should the plan of care include today to prepare for the test tomorrow?
Encourage plenty of fluids. The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test
A 56-year-old male patient who has COPD is refusing to eat. Which intervention would be most helpful in stimulating his appetite?
Encouraging food from home when possible. Food from home that the patient enjoys may stimulate him to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what he must eat is no guarantee that he will comply.
A client is diagnosed with pyelonephritis. Which nursing action is a priority for care now?
Ensure sufficient hydration. Explanation: The nurse should ensure the client has adequate hydration. A urinary catheter is discouraged because of the risk of urinary tract infection. Monitoring of the hemoglobin level is not necessary for clients with pyelonephritis. Although antibiotics may be prescribed for long-term management and for chronic pyelonephritis, at this time the nurse should focus on helping the client maintain hydration.
The nurse is scheduling tests for a patient who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?
Fecal occult blood test, barium studies, endoscopic examination 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 test are done in the correct order. Fecal occult blood test, barium studies, and endoscopic examination is the correct order of the exams and tests.
A client who gave birth 24 hours ago continues to experience urine retention after several catheterizations. The physician orders bethanechol, 10 mg by mouth three times per day. The client asks, "How does bethanechol act on the bladder?" How should the nurse respond?
It stimulates the smooth muscle of the bladder." Bethanechol stimulates the smooth muscle of the bladder, causing it to release retained urine. Bethanechol doesn't act on the urinary sphincter or dilate the urethra. The bladder contains smooth muscle, not skeletal muscle
A patient undergoes surgery for removing a malignant tumor, followed by a urinary diversion procedure. The nurse's postoperative plan of care should include which of the following?
Maintain skin and stomal integrity. The most important postoperative nursing management is to maintain skin and stomal integrity to avoid further complications, such as skin infections and urinary odor. Determining the patient's ability to manage stoma care, showing photographs, and suggesting a visit to a local ostomy group would be a part of the preoperative procedure
The nurse has administered mannitol IV. Which is a priority assessment for the nurse to make after administering this drug?
Monitor urine output. Mannitol is an osmotic diuretic used in acute clinical situations. It increases osmotic pressure and draws fluid into the vascular space. Monitoring hourly urine output is a priority nursing assessment when administering mannitol. Electrolyte levels should also be monitored, most specifically sodium, chloride, and potassium. Calcium levels are not affected by mannitol. Assessing for bowel sounds and checking pupil reaction to light are not priority nursing assessments when administering mannitol.
A patient is suspected of having a disease process affecting the functional unit of the kidney. The nurse correctly recognizes which of the following stuctures is most likely involved?
Nephron The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman's capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman's capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.
A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the irrigant will not enter the catheter. What intervention would the nurse appropriately perform next?
Notify the primary care provider.
A nurse working on an acute care urology unit is assigned to a client who requires hourly urine measurement. The previous two urine measurements have been within normal limits. The next urine measurement is now due, but the nurse is busy and running late with medication administration. Which of the following actions should the nurse take?
Obtain the urine measurement as scheduled and request help with medications. The nurse is expected to assess the client's hourly urine output. When busy, a nurse may seek assistance from other nurses on the team to help with tasks. The other options are incorrect because they do not reflect safe and competent nursing care. Falsifying legal documents is unethical. If the client is caused harm as a result of this behavior, the nurse could be accused of malpractice
A nurse is caring for a male patient who had a condom catheter applied following hip surgery. What action would be a priority when caring for this patient?
Preventing the tubing from kinking to maintain free urinary drainage
A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention would the nurse initiate for this patient?
Provide a thirty-minute rest period prior to mealtime. - When feeding a patient who has dysphagia, the nurse should provide a 30-minute rest period prior to mealtime to promote swallowing; alternate solids and liquids when feeding the patient; sit the patient upright or, if on bedrest, elevate the head of the bed at a 90-degree angle; and initiate a nutrition consult for diet modification and food size and/or consistency.
An indwelling urinary catheter has been ordered for a client experiencing urinary retention after surgery. When the nurse enters the room to place the catheter, the client reports voiding in the bathroom. What is the nurse's most appropriate action?
Reassess if the urinary catheter is still necessary for the client. Before any intervention is implemented, the nurse should assess if the intervention is still indicated. Since the client has reported voiding, the nurse should take measures to see if the client is still retaining urine. The nurse cannot tell the client the catheter is necessary until after the assessment is complete. The nurse should wait until the assessment is complete before deciding whether the catheter is indicated.
Which of the following is a factor that contributes to urinary incontinence in the older female adult?
Relaxed perineal muscle
A nurse is feeding a patient who states that she is feeling nauseated and can't eat what is being offered. What would be the most appropriate initial action of the nurse in this situation?
Remove the tray from the room. - The first action of the nurse when a patient has nausea is to remove the tray from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect.
A 58-year-old woman is suffering from food poisoning after eating at a local restaurant. She has had nausea, vomiting, and diarrhea for the past 12 hours. Her blood pressure is 88/50 and she is diaphoretic. She requires
Replacement of fluids for those lost from vomiting and diarrhea The therapeutic goal may be maintenance, replacement, treatment, diagnosis, monitoring, palliation, or a combination. This client requires intravenous fluids for replacement of those lost from vomiting and diarrhea.
Blood shed in sufficient quantities into the upper GI tract, produces which color of stool?
Tarry-black Blood shed in sufficient quantities into the upper GI tract produces a tarry-black stool. Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. A milky white stool is indicative "of" a patient who received barium. A green stool is indicative of a patient who has eaten spinach.
A nurse is caring for a newly placed gastrostomy tube of a postoperative patient. Which nursing action is performed correctly?
The nurse dips a cotton-tipped applicator into sterile saline solution and gently cleans around the insertion site.
A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced?
The patient reports fullness and diarrhea after breakfast. - Tolerance of diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray.
A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia?
The stoma is a purple-blue color.
A community nurse is assessing a young child who has had a colostomy stoma for several years. The nurse notices that the stoma is dark pink and moist. What is the best response to the child's parents about the appearance of the stoma?
The stoma looks healthy; continue your present care." A normal, healthy stoma should be dark pink and moist.
Which therapy uses low-level radiofrequencies to produce localized heat that destroys prostate tissue?
Transurethral needle ablation Transurethral needle ablation uses low-level radiofrequencies to produce localized heat that destroys prostate tissue while sparing the urethra, nerves, muscles, and membranes. Sal palmetto is a herbal product used to treat the symptoms associated with benign prostatic hyperplasia. Microwave thermotherapy involves the application of heat to the prostatic tissue. Resection of the prostate can be performed with ultrasound guidance.
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
Two to 3 soft bowel movements daily
The nurse is conducting a gastrointestinal assessment. When the patient complains of the presence of mucus and pus in his stools, the nurse assesses for additional signs/symptoms of which of the following disease/conditions?
Ulcerative colitis
The nurse is conducting a gastrointestinal assessment. When the patient complains of the presence of mucus and pus in his stools, the nurse assesses for additional signs/symptoms of which of the following disease/conditions?
Ulcerative colitis The presence of mucus and pus in the stools suggests ulcerative colitis. Watery stools are characteristic of small-bowel disease. Loose, semisolid stools are associated more often with disorders of the colon. Voluminous, greasy stools suggest intestinal malabsorption.
Through the prevention of postoperative complications, the nurse promotes rapid convalescence. Which of the following would be most indicative of a potential postoperative complication in a client that requires further observation?
Urinary output of 20 mL/hr over 2 hours Urine output is maintained at a minimum of 30 mL/hr in adults. Less than this for 2 consecutive hours should be reported to the physician. A low-grade fever is expected in healing and is the natural inflammatory response to surgery. Moderate drainage can be observed, and the blood pressure is still within normal parameters
The nurse is assessing a patient for constipation. Which of the following is the first factor the nurse should review to identify the cause of constipation?
Usual pattern of elimination
The nurse is assessing a patient for constipation. Which of the following is the first review that the nurse should conduct in order to identify the cause of constipation?
Usual pattern of elimination
A 62-year-old male patient has been admitted to the alcoholic referral unit in the local hospital. Based on an understanding of the effects of alcohol on the GI tract, which is a priority concern related to nutrition?
Vitamin B malnutrition - The need for B vitamins is increased in alcoholics because these nutrients are used to metabolize alcohol, thus depleting their supply. Alcohol abuse specifically affects the B vitamins. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract.
The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements?
Void immediately after sexual intercourse Voiding will serve to flush the urethra, expelling contaminants. Showers are encouraged rather than tub baths because bacteria in the bath water may enter the urethra. Coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants should be avoided. The patient should be encouraged to void every 2 to 3 hours during the day and completely empty the bladder.
A sterile urine specimen for culture and sensitivity has been ordered for a patient who has an indwelling urinary catheter. How should the nurse obtain this specimen?
Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle. When it is necessary to collect a urine specimen from a patient 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 patient's catheter would not be removed for the sole purpose of obtaining a urine specimen.