Saunders Nclex-PN - Elimination

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? *Select all that apply.* 1.Placing the scan head on the symphysis pubis and aiming toward the bladder 2.Pressing and holding the done button to display the volume measurement and print results 3.Applying a generous amount of transmission/conductivity gel across the client's abdomen 4.Pressing the gender button to select the male setting and wiping the scan head with an alcohol pad 5.Turning on the scanner by pressing the on/off button and then the scan button to turn on the scanning screen 6.Assisting the client to a supine position with head elevated on a pillow and exposing the client's lower abdomen

(1 & 3) Rationale: A bladder scan is a portable ultrasound used to estimate the amount of urine in the bladder. The student nurse should apply the conductivity gel 2.5 to 4 cm above the symphysis pubis, not across the abdomen. The scan head is placed in this area and aimed toward the client's head and slightly downward toward the coccyx, not downward on the symphysis pubis. The supine position is correct. The scanner is turned on and the male setting is used with a female client without a uterus (status post hysterectomy). The scan head is cleansed with alcohol before the scan. Once the scanner head is positioned the button is pushed to display the urine in the bladder. The nurse observes the picture on the scanner to make sure the picture on the screen correctly depicts the urine. The volume measurement is printed or noted and documented in the client's medical record. The client needs to be placed in the proper position before the scanner is turned on and gender is selected. After applying gel, the bladder can be scanned. Once the bladder is scanned, the volume measurement should be displayed and the results printed.

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? *Select all that apply.* 1.Apply disposable gloves. 2.Place the client in the right Sims' position. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 5.Hang the enema solution container 24 inches above the client's anus. 6.Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

(1,3,4 & 6) Rationale: The administration of an enema is a clean procedure, and standard precautions must be used. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort subsides. The container containing the enema solution is hung about 12 to 18 inches above the client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between 100° F (37.8° C) and 105° F (40.5° C). Solution that is too hot will burn the client, and solution that is too cool will cause cramping.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon? 1.Immediately inflate the balloon. 2.Insert the catheter 2.5 cm to 5 cm and inflate the balloon. 3.Advance the catheter to the bifurcation and inflate the balloon. 4.Insert the catheter until resistance is met and inflate the balloon.

3.Advance the catheter to the bifurcation and inflate the balloon. Rationale: Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine and then continues to advance the catheter to the point of bifurcation and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The balloon should not be inflated when urine is first observed, after advancing several more centimeters or when resistance is felt.

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the *need for further teaching? Select all that apply.* 1.Assess the stoma and skin. 2.Remove the used pouch and barrier. 3.Perform hand hygiene and don gloves. 4.Lightly scrub the stoma with soap and water. 5.Press the adhesive backing of the pouch against the skin. 6.Cut the opening on the appliance ½ inch larger than stoma.

(4 & 6) Rationale: The client washes the hands and dons gloves before removing the pouch and barrier. The peristomal area is cleansed with warm water to remove residue and improve visualization. The stoma is assessed for color, and the skin is checked for irritation. The appliance is measured and cut 1/16 inch larger than stoma to prevent strangulation of stoma, or too much room for skin irritation between the stoma and appliance. The adhesive backing of the appliance is pressed against the skin avoiding wrinkles to achieve seal.

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? 1 2 3 4

3 Rationale: Long-term indwelling catheters are used with severe urinary retention, recurrent urinary tract infections, and when wounds are irritated by contact with urine. Silicon is preferred because it can stay in place for 2 to 3 months. Size 14 to 16 are standard sizes, and only sterile water should be used to inflate the balloon. Saline will crystallize in the balloon. Intermittent and short-term catheterization would not solve the issue of severe urinary retention and would require repeated catheterization, increasing risk of infection. A condom catheter will not remedy urinary retention and does not have a balloon.

Which ostomy location would most likely need to be irrigated? Refer to figure. A) Asending B) Proximal Transverse C) Distal Transverse D) Descending

D Rationale: The ostomy located at the juncture of the descending and sigmoid colon would be most likely to need irrigating because the effluent would be the most solid. Effluent in the ascending colon would be mostly liquid, and would become more solid as fluid is absorbed during passage through the transverse colon.

Which factors contribute to the problem of stress incontinence? *Select all that apply.* 1.Obesity 2.Sneezing 3.Nulliparity 4.Performing Kegel exercises 5.Voiding at frequent intervals

(1 & 2) Rationale: Obesity contributes to stress incontinence by causing increased intra-abdominal pressure. Sneezing or laughing also often cause leakage of urine due to sudden increased intra-abdominal pressure. Nulliparity refers to never having given birth and is not a factor of stress incontinence; rather, a history of having three or more vaginal births is associated with stress incontinence due to the weakening of the pelvic floor muscles. Performing Kegel exercises is actually a means of strengthening muscle tone. Voiding at frequent intervals, such as every 2 hours decreases the volume of urine in the bladder, thus decreasing the stretch and pressure in the bladder, and lessening the chance of incontinence.

The client is to receive a soapsuds enema. Which is the *best* position for administering an enema? a left sidelining b prone c lithotomy d knee chest

(1) Rationale: The Sims, or left lateral position, is the position of choice for enema administration facilitating fluid to pass farther in the intestine. Many clients cannot tolerate the prone position. The lithotomy position is impractical for the procedure, and knee chest is too uncomfortable.

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply. 1. Maintain adequate fluid intake of 2 quarts. 2. Urinate regularly every 8 hours during the day. 3. Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. 4. Take all discharge medication as prescribed including antibiotics, and notify your primary health care provider if symptoms or signs of a UTI reappear. 5. Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating.

(1, 3, 4 & 5) Rationale: Besides taking all discharge medications as prescribed, including antibiotics, and notifying the primary health care provider if symptoms/signs of a UTI reappear, it is also important for the client to take adequate fluid amounts and use appropriate hygiene to prevent microorganisms from entering the bladder. Vaginal douches need to be avoided along with other products that can potentially irritate the perineal area. The client must be told to urinate at least every 4 to 6 hours.

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. *Select all that apply.* 1.Check the bladder for distention. 2.Review intake and output record. 3.Check to ensure drainage tubing is not kinked. 4.Ask the client about bladder spasms and discomfort. 5.Raise the drainage bag to the height of the bladder. 6.Deflate the balloon of the catheter, advance the catheter 2 cm, and reinflate the balloon.

(1,2,3 & 4) Rationale: A continuous bladder irrigation is often prescribed after a TURP to prevent blood clot formation that will obstruct the catheter. A drainage tube that is kinked will not allow the bladder irrigation solution to exit the body and can be done quickly while observing the system setup. Assessing the bladder for distention would follow because a clot may be preventing drainage. Asking the client if there is any discomfort or spasms may indicate improper drainage. Reviewing the intake and output record is done because the nurse can see that fluid is entering the system but not leaving. Raising the drainage bag will cause the urine to backflow into the bladder or stop flow. Deflating the balloon and advancing the catheter should not be done because this will introduce bacteria into the system.

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? *Select all that apply.* 1.Increase your fluid intake. 2.Include more fiber in your diet. 3.Ferrous sulfate changes the color of stool to black. 4.Iron slows colonic acid and often leads to constipation. 5.Use an enema every other day if you don't have a bowel movement. 6.Signs of constipation include not having a bowel movement every day.

(1,2,3 & 4) Rationale: As motility slows, feces are exposed to the intestinal walls and water is absorbed. Increasing fluid intake will help by adding more fluid to the intestinal contents. Fiber increases motility. Iron and several other medications slow motility. Lack of exercise or bed rest contributes to constipation. An enema should not be used every other day, usually no more frequently than on the third day. Many people do not have bowel movements every day. Constipation is not having a bowel movement in 3 days.

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? *Select all that apply.* 1.Character of drainage 2.Presence of blood clots 3. Amount of drainage emptied 4.Client complaint of pain/spasms 5. Type and amount of irrigation fluid used 6. Frequency of emptying the drainage bag

(1,2,3,4 & 5) Rationale: Options 1, 2, 3, 4, and 5 are all correct because they all are indications of the effectiveness of the bladder irrigation. Character of drainage describes details such as color and sediment and is a means of evaluating effectiveness of irrigation. Presence and size description of blood clots, complaints of spasms, type and quantity of solution infused, and amount of solution returned all provide information as to effectiveness of procedure and client status. Option 6 is incorrect because it is not necessary to document how frequently the drainage bag was emptied, but the amount of irrigation fluid that went in and the total amount of drainage emptied should be documented so that the actual urine output can be calculated by subtracting the input from the output.

The nurse should recognize that which type of enema has the highest risk of water intoxication? 1. Soapsuds 2. Tap water 3. Normal saline 4. Hypertonic solution

(2) Rationale: Tap water is hypotonic, creating a lower osmotic pressure than the fluid in interstitial spaces. With repeated tap water enemas, fluid can escape from the bowel lumen into interstitial spaces and can cause circulatory overload or water intoxication if the body absorbs too much water. Normal saline enemas are the safest type of enema because of having the same osmotic pressure as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not cause any fluid shifts but may not be effective in evacuating the bowel. Castile soap is incorrect because it can be mixed with either water or saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is the only safe soap to use for a soapsuds enema because harsh soaps may cause inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull fluid from the interstitial spaces into the colon. Although this could have the potential for dehydration, it does not pose as high of a risk of complications as the tap water enema. A Fleets enema (commercially prepared sodium phosphate) is the most common type of hypertonic enema.

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply. 1.Change the appliance daily. 2.Empty pouch when ⅓ to ½ full. 3.The stoma should be a dry pale pink. 4.The stoma should be moist and pink to red. 5.The skin barrier should be within 1⁄16 to ⅛ inch of the stoma. 6.Change the appliance about every 3 days, or sooner, if it is leaking effluent.

(2,4,5 & 6) Rationale: The pouch should be emptied when ⅓ to ½ full to prevent the weight of contents from loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to within 1⁄16 to ⅛ inch of the base of the stoma prevents effluent from irritating the skin. With an adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2 weeks. Changing the appliance daily would damage the skin around the stoma. A dry pale pink is indicative of an unhealthy stoma and possibly dehydration.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason? 1.The nurse is right handed. 2.The rectal sphincter will relax. 3.The enema will flow into the bowel easily. 4.The client is more likely to retain the enema solution.

(3) Rationale: When administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

An older client complains of chronic constipation. Which instructions should the nurse reinforce with the client? *Select all that apply.* 1.Include rice and bananas in the diet. 2.Increase the intake of sugar-free products. 3.Increase fluids to at least eight glasses a day. 4.Increase various potassium-rich foods in the diet. 5.Respond in a timely manner to the urge to defecate.

(3,5) Rationale: Increase of fluid intake and dietary fiber will help change the consistency of the stool and make it easier for the client to pass. Clients should respond to the feeling of peristalsis involved with urge to defecate. Some older clients with mobility issues may not respond to the urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client.

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? *Fill in the blank.* ____ mL

250mL Rationale: 200 mL × 8 hr = 1600 mL, which is the amount of normal saline infused. 850 − 1600 = 250 (total in receptacle minus irrigation)

A client has been diagnosed with functional incontinence. Which interventions are *most appropriate* to care for this type of incontinence? *Select all that apply.* 1.Schedule toileting every 2 hours. 2.Modify clothing for easy removal. 3.Assess environment for obstacles. 4.Decrease fluid intake to 1500 mL/day. 5.Obtain prescription for catheterization to eliminate embarrassment. 6.Set up schedule of cues such as mealtimes, awakening, and bedtime.

(1,2,3 & 6) Rationale: Functional incontinence is loss of urine by factors outside the urinary tract that interfere with the ability to respond in a socially appropriate way to the urge to void. It may be an inability or unwillingness of a person with normal bladder function to get to the bathroom in time, environmental barriers (e.g., raised side rails), physical limitations (e.g., can't walk self to bathroom), or mental factors (e.g., disorientation). Interventions include such things as clothing modifications, environmental alterations, scheduled toileting, and absorbent products. Therefore, option 2 is correct because modifying clothing to use Velcro or easy fasteners can save time in reacting to urge. Option 1 is correct because toileting every 2 hours will prevent overfilling of the bladder. Option 3 is correct because environmental obstacles such as poor lighting or lack of assistive devices can make it difficult to reach the toilet in a timely manner. Option 6 is correct because establishing a schedule will provide reminders to use the toilet. Option 4 is incorrect because decreasing fluid intake to below 2000 mL will irritate the bladder and may contribute to incontinence and may increase risk of infection. Option 5, catheterization, is incorrect because it contributes to risk of infection.

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? *Select all that apply.* 1.Obtain the bladder scan before the client voids. 2.Have the client void and then perform the bladder scan. 3.If residual urine is less than 100 mL, continue to monitor. 4.Reduce oral fluid intake to decrease amount of residual urine. 5.Straight catheterize the client if 100 mL of urine is viewed on the scan. 6.Notify the primary health care provider immediately if 30 mL of urine is viewed on the scan.

(2 & 3) Rationale: To obtain a residual urine, it is necessary for the client to void, then obtain a bladder scan. If less than 100 mL of urine (or the specific amount prescribed) is viewed on the scan, continuing to monitor as prescribed is appropriate. Obtaining the scan before voiding would tell the nurse how much fluid the bladder can hold. Decreasing fluids may lead to dehydration and will not affect residual urine. Notifying the primary health care provider of normal findings is inappropriate, as is catheterizing for 100 mL of residual urine.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement? 1."I walk 1 to 2 miles per day." 2."I need to decrease fiber in my diet." 3."I drink 6 to 8 glasses of water per day." 4."I have a bowel movement every other day."

(2) Rationale: Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.