Elimination
which education would the nurse provide the parent of a boy born with hypospadias about the age in which the repair of this congenital defect is typically performed? 1. shortly after birth 2. between 4 and 5 years of age 3. just before the onset of puberty 4. after 6 months and before 1 year of age
4
a client with severe Crohn disease develops a small bowel obstruction. which clinical finding would the nurse expect the client to report? 1. blood vomitus 2. projectile vomiting 3. bleeding and defecation 4. pain in the left lower quadrant
2
which intervention would prevent urinary stasis and formation of renal calculi in an immobile client? 1. increasing oral fluid intake to 2 to 3 L/day 2. maintaining bed rest after discharge 3. limiting fluid intake to 1 L/day 4. voiding at least every hour
1
which factor would the nurse assess for a client reporting constipation? select all that apply 1. diet 2. fluid intake 3. use of laxatives 4. date of last BM 5. use of opioid pain medications
1, 2, 3, 4, 5
which action would the nurse implement in a male client who reports an inability to void after undergoing a cystoscopy and biopsy of the prostate gland due to dysuria, nocturia, and difficulty starting a urinary system? 1. insert a urinary retention catheter 2. palpate above the pubic symphysis 3. limit oral fluids until the client voids 4. assure the client that this is expected
2
which intervention would the nurse implement when providing care for an older adult male client who is immobile and in content of urine? 1. restrict the client's fluid intake 2. regularly offer the client a urinal 3. apply incontinence parts 4. insert an indwelling urinary catheter
2
which action would the nurse include when developing a post procedure plan of care for a client with continuous bladder irrigations after a transurethral vaporization of the prostate? 1. measure the output hourly and monitor total output trends 2. monitor the specific gravity of the urine each shift 3. irrigate the triple-lumen catheter with normal saline three times daily 4. deduct the amount of instilled irritant from the total output
4
which clinical manifestation would the nurse associate with benign prosaic hyperplasia? 1. perineal edema 2. urethral discharge 3. flank pain radiating to the groin 4. distention of the lower abdomen
4
after a transurethral resection of the prostate, the retention catheter is pulled taut and secured to the client's leg. the client reports a feeling of pressure and asks why this is necessary. which rationale would the nurse include in a response to this question? 1. prevents bleeding 2. limits discomfort 3. reduces bladder spasms 4. promotes urinary drainage
1
which action would be appropriate to implement when collecting a 24 hour urine test? 1. start the time of the test after discarding the first voiding 2. discard the last voiding int eh 24 hour period for the test 3. insert a urinary retention catheter to promote the collection of urine 4. strain the urine after each voiding before adding the urine to the container
1
which action would the nurse take when a client has returned from surgery with a nephrostomy tube? select all that apply 1. ensure free drainage of urine 2. milk the tube every 2 hours 3. keep an accurate record of intake and output 4. instill 12 mL of normal saline every 8 hours 5. observe and document urine characteristics
1, 3, 5
which plan of care would the nurse provide for a newborn with hypospadias? 1. preparing the infant for insertion of a cystostomy tube 2. explaining to the parents the genetic basis for the defect 3. keeping the infant's penis wrapped with petrolatum gauze 4. giving the parents reasons why circumcision should not be performed
4
which goal is the nurse trying to achieve with continuous bladder irrigation's (CBI) of a client who has undergone a suprapubic prostatectomy for cancer of the prostate? 1. stimulate continuous formation of urine 2. facilitate the measurement or urinary output 3. prevent the development of clots in the bladder 4. provide continuous pressure on the prostatic fossa
3
which goal would the nurse establish when providing care for a client recovering from a TURP? 1. maintain patency of the cystostomy tube 2. prevent wound hemorrhage and infection 3. maintain patency of the indwelling catheter 4. prevent the abdominal dressing from draining
3
which information would the nurse provide about what the client can expect after surgery for a TURP? 1. "urinary control may be permanently lost to some degree" 2. "an indwelling urinary catheter is required for at least a day" 3. "your ability to perform sexually will be impaired permanently" 4. "bruning on urination will last while the cystostomy tube is in place"
2
after abdominal surgery, a client's postoperative prescriptions include a NGT to lower intermittent wall suction and an antiemetic every 6 hours as needed for nausea. when the client reports feeling nauseated, which action would the nurse take first? 1. check for correct placement of the NG tube 2. administer the prescribed antiemetic 3. assess the client's bowel sounds 4. notify the primary health care provider
1
which instruction would the nurse include in a health practices teaching plan for a female client with a history of recurrent urinary tract infections? 1. "wear cotton underwear or lingerie" 2. "void at last every 6 hours around the clock" 3. "increase foods containing alkaline ash in the diet" 4. "wipe the perineum from back to front after toileting"
1
which intervention is most important is preventing hospital-acquired catheter-associated urinary tract infection (CAUTIs)? 1. removing the catheter 2. keeping the drainage bag off the floor 3. washing hands before and after assessing the catheter 4. cleansing the urinary meatus with soap and water daily
1
a client develops an intestinal obstruction. a NG tube is inserted and connected to low, continuous suction. the nurse monitors the client for fluid volume deficit. which clinical finding would the nurse expect if the client becomes dehydrated? 1. restlessness 2. constipation 3. inelastic skin turgor 4. increased blood pressure
3
a parent tells the clinic nurse that their 6 yo child has been wetting the bed for the past 3 weeks. previously there had been no problems. how would the nurse respond? 1. "try to eliminate fluids after dinner" 2. "children sometimes wet the becd when they're angry" 3. "you did the right thing to bring your child in the be examined" 4. "wake your child every few hours at nigh to go to the bathroom"
3
which action would the nurse take when a client returning to the unit after a transurethral vaporization of the prostate with an indwelling urinary catheter and a continuous bladder irrigation reports the need to urinate? 1. encourage the client to drink fluids 2. review the client's intake and output 3. assess that the tubing attached to the collection bags patent 4. explain that the balloon inflated in the bladder causes this feeling
3
which nursing action would the nurse monitor during the initial recovery phase of a client returning to the post anesthesia care unit with a three-way indwelling catheter and a continuous bladder irrigation after a transurethral prostatectomy (TURP)? 1. observe the suprapubic dressing for drained 2. maintain the client in the semi-fowler position 3. monitor for bright red blood in the urinary drainage bag 4. encourage fluids by mouth as soon as the gag reflex returns
3
which primary symptom would the nurse assess for in a child who has encopresis? 1. practicing self-mutilation 2. practicing self-induced vomiting 3. passing feces either voluntarily or involuntarily into inappropriate places 4. passing urine either voluntarily or involuntarliy into inappropriate places
3
which statement made by an older adult most strongly supports the. nurse's conclusion that the client has impacted stool? 1. "I have a lot of gas pain" 2. "I don't have much of an appetite" 3. "I feel like I have to go, but I just seep" 4. "I haven had a bowel movement for several days"
3
which condition would the nurse suspect in a client who complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination with a digital rectal examination report indicating smooth, firm, and enlarged prostate tissue surrounding the urethra? 1. prostatitis 2. paraphimosis 3. prostate cancer 4. benign prostatic hyperplasia (BPH)
4
which finding would the nurse expect when assessing a client who has a ureteral calculus? 1. foul odor and dark urine 2. urgency and mild aching pain 3. frequency with small amounts of urine 4. hematuria with sharp pain when voiding
4
which action would the nurse implement when providing care for a client with continuous bladder irrigations? 1. monitor urinary specific gravity to determine hydration 2. subtact irrigation from output to determine urine volume 3. record urinary output every hour to determine kindly function 4. obtain a 24-hour urine specimen to determine urine concentration
2
which condition would the nurse suspect in a client admitted to the hospital with severe renal colic caused by a ureteral calculus who later that evening has a urinary output much less than the intake with the bladder not being distended? 1. oliguria 2. hydroureter 3. renal shutdown 4. urethral obstruction
2
a client admitted to the hospital with a small bowel obstruction is scheduled to have an intestinal tube inserted. when preparing the client for the procedure, which action would the nurse take? 1. place the client in the right side-lying position 2. instruct the client about techniques for mouth breathing 3. spray the client's oropharynx with a local anesthetic solution 4. reassure the client that the procedure will not cause discomfort
2
which nursing action during a focused urinary assessment would the nurse use to collect subjective client data? select all that apply 1. inquire about painful urination 2. ask the client about changes in characteristics of urination 3. assess the levels of blood urea nitrogen and creatinine 4. palpate the abdomen for bladder distention or masses 5. inspect the urinary meatus for inflammation or discharge
1, 2
the nurse administers an older adult client's medications via gastrostomy tube in the long-term care setting. which finding would necessitate holding the feedings and medications and notifying the health care provider immediately? select all that apply 1. absence of bowel sounds 2. presence of abdominal distention 3. residual capacity exceeding 300 mL 4. positive guaiac test of abdominal contents 5. seepage of feeing around tracheostomy
1, 2, 3, 4, 5
which parental statement indicates effective learning regarding management of nocturnal enuresis in a 6 yo child? select all that apply 1. "I should avoid giving my child fluids after dinner" 2. "I should encourage my child to drink lots of water during the day" 3. "I should make my child wear diapers during day hours while at school" 4. "I should give my child diet soda instead of regular soda in the evening" 5. "I should wake my child at the same time every night to use the bathroom"
1, 2, 5
which clinical manifestation of a UTI would the nurse teach to a male client with a history of recurrent urinary tract infections (UTIs) when preparing for discharge after a ureterolithotomy? 1. urgency or frequency of urination 2. an increase of ketones in the urine 3. the inability to maintain an erection 4. pain radiating to the external genitalia
1
which instruction would the nurse share when discussing prevention in a female leant with a cycle of recurring urinary tract infections? 1. "urinate as soon as possible after intercourse" 2. "increase your daily intake of citrus juice" 3. "douche regularly with alkaline agents" 4. "take bubble baths on a frequent basis"
1
the parent of a 6 yo boy tells the nurse in the pediatric clinic that their son has recently started to wet the bed at night. which is the most helpful response by the nurse? 1. "how's your son doing in school?" 2. "have there been nay changes in his life recently?" 3. "you should arrange to see the health care provider, because there may be a physical problem" 4. "when children are angry at their parents, they may use bedwetting to punish them"
2
which postoperative care instructions would the nurse include when providing preoperative teaching for a client scheduled for a transurethral resection of the prostate (TURP)? 1. the urine will be bright red for 24 to 48 hours 2. spasms of the bladder occur during the first 24 to 48 hours 3. to decrease bladder contractions, the Valsalva maneuver and Kegel exercises will be encourage 4. to maintain proper fluid balance, oral fluids are restricted during continuous urinary bladder irrigations
2
which statement would be made by the nurse when performing pre surgical teaching for a client pending a TURP? 1. "urinary control may be permanently lost to some degree" 2. "an indwelling urinary catheter is required for at least 1 day" 3. "your ability to perform sexually will be impaired permanently" 4. "burning on urination will last while the cystostomy tube is in place"
2
which type of urinary condition would cholinergic agnostic be prescribed for? 1. kidney stones 2. urine retention 3. spastic bladder 4. urinary tract infections
2
which intervention would the nurse implement for a client with a ureteral calculus? select all that apply 1. limiting fluid intake at night 2. monitoring intake and output 3. straining the urine at each voiding 4. recording the client's blood pressures 5. administering the prescribed analgesic
2, 3, 5
which action would the nurse implement to prevent a client with urinary retention and an indwelling urinary catheter from developing a urinary tract infection? 1. assess using specific gravity 2. collect a weekly urine specimen 3. maintain the prescribed hydration 4. empty the drainage bag once a day
3
which finding of a client several hours after removal of a catheter inserted a week prior after pelvic surgery indicates a need for reinsertion oft he catheter? 1. anuria 2. polyuria 3. retention 4. incontinence
3
which information about benign prostatic hyperplasia (BPH) is important for the nurse to consider when caring for a client with that condition? 1. it is a congenital abnormality 2. a malignancy usually results 3. it predisposes ti hydronephrosis 4. prostate-specific antigen decreases
3
which is an appropriate short-term goal for a child with enuresis? 1. groin rash will resolve in 1 week 2. continence will be maintained throughout the night 3. the interval between voiding will increase by 1 hour 4. self-esteem enhancement will occur when the child is given praise
3
which clinical indicator during the postoperative period of a client who had a successful nephrolithotomy to remove renal calculi would the nurse monitor and report immediately to the primary health care provider? 1. continuous passage of pink-tinged urine 2. pink drainage on the client's surgical dressing 3. total intake volume of 2000 mL in 24 hours 4. urinary output of 20 to 30 mL/h
4
which condition would the nurse suspect if the client reports passing urine involuntarily while coughing? 1. enuresis 2. pneumaturia 3. urinary retention 4. stress incontinence
4
which factor may contribute to a client developing urinary calculi? 1. increased fluid intake 2. urine specific gravity of 1.017 3. jogging 3 miles a day 4. history of hyperparathyroidism
4
which intervention would the nurse implement first in a client who has a ureteral calculus and is admitted to the hospital with severe flank pain, nausea, and hematuria? 1. strain all urine output 2. increase oral fluid intake 3. obtain a urine specimen for culture 4. administer a prescribed analgesic
4
which response would the nurse provide to a client who asks about what to expect postoperatively before a TURP? 1. "your urine will be pink and free of clots" 2. "you will have an abdominal incision and a dressing" 3. "there will be an incision between your scrotum and rectum" 4. "there will be urinary catheter and a continuous bladder irrigation"
4