NCLEX Elimination

A client has a continuous catheter irrigation postoperatively after having a transurethral resection of the prostate. The nurse notes that fluid is entering the bladder, but none appears to be draining. In priority order, which actions should the nurse take? Arrange the actions in the order they should be performed. All options must be used.

Check to ensure drainage tubing is not kinked. Check the bladder for distention. Ask the client about bladder spasms and discomfort. Review intake and output record.

Pregnancy Increase in fluid intake UTI

Frequency or nocturia

An older client complains of chronic constipation. Which instructions should the nurse give to the client?

Increase fluids to at least eight glasses a day.

A client receiving iron supplements (ferrous sulfate) 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.

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.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should assist the client to which position?

Left Sims' position, with the head of the bed flat

Decrease in fluid intake Dehydration Presence of hypotension, shock, or heart failure History of kidney disease Presence of elevated BUN (blood urea nitrogen) and serum creatinine Edema, hypertension (retention of fluids)

OLIGURIA AND ANURIA

Certain fluids, such as -----, increase fluid output by inhibiting the production of antidiuretic hormone (ADH) a. alcohol b. water c.Tea d. saline solution

a. alcohol

Factors affecting urinary elimination? select all that apply a. genetics b. fluid and food intake c. muscle tone d. gas exchange e. surgeries

b, c, e

what is the avg daily urine output for an adult a. 1200 b. 1000 c.2300 d. 1500

d. 1500

When abnormal amounts of fluid are lost through another route (e.g., vomiting, high fever), the kidneys --- water, and urinary output --- a. release/ decrease b. realease/increase c. retain/increase d. retain/ decrease

d. retain/ decrease

food and liquids high in -----may cause fluid retention. a. protein b. fiber c. carbs d. sodium

d. sodium

Urinary tract inflammation, infection, or injury Hesitancy, hematuria, pyuria (pus in the urine), and frequency

dysuria

Family history of enuresis Difficult access to toileting facilities Psychologic stress

enuresis

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

"I need to decrease fiber in my diet."

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

. Empty pouch when 1/3 to ½ full. The stoma should be moist and pink to red. The skin barrier should be within 1/16 to 1/8 inch of the stoma. Change the appliance about every 3 days, or sooner if it is leaking effluent.

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 decubitus on the coccyx? Refer to chart.

3 - Long term

The client is to receive a Fleet enema. Which is the best position for administering an enema? Refer to figure.

A

medications, particularly those affecting the autonomic nervous system, interfere with the normal urination process, leading to the retention of urine. These include:

Anticholinergic and antispasmodic medications, such as atropine and papaverine Antidepressant and antipsychotic agents, such as phenothiazines and monoamine oxidase inhibitors Antihistamine preparations, especially those containing pseudoephedrine (e.g., Claritin-D, Sudafed) Antihypertensive agents, such as hydralazine (Apresoline) and methyldopa (Aldomet) Antiparkinsonism drugs, such as levodopa, trihexyphenidyl (Artane), and benztropine mesylate (Cogentin) Beta-adrenergic blockers, such as propranolol (Inderal) Opioids, such as hydrocodone (Vicodin)

The nurse is using a bladder scanner to determine a client's post-void residual (PVR). Which priority order should the nurse employ to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.

Assist client to a supine position with head elevated on a pillow and expose the client's lower abdomen. Turn on the scanner by pressing the on/off button and then the scan button to turn on the scanning screen. Press the gender button to select the male or female setting and wipe the scan head with an alcohol pad. Apply a generous amount of transmission/conductivity gel 2.5 to 4 cm above the symphysis pubis. Place the scan head on the gel with the directional icon toward the client's head, and direct it toward the bladder. Press and hold the done button to display the volume measurement and print results.

increase urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into the bloodstream. select all that apply A. Antihistamine B. diurectics C. furosemide D. Chlarynzapil E. Chlorothiazide

B, C, E

Which ostomy location would most likely need to be irrigated? Refer to figure.

D

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.

Have the client void and then do the bladder scan If residual urine is less than 100 mL, continue to monitor

Which factors contribute to the problem of stress incontinence? Select all that apply.

Obesity Sneezing

What are the steps in order of priority for application of an ostomy appliance? Arrange the actions in the order they should be performed. All options must be used.

Perform hand hygiene and don gloves. Remove the used pouch and barrier. Cleanse the peristomal area with warm water. Assess the stoma and skin. Cut the opening on the appliance 1/16 inch larger than stoma. Press the adhesive backing of the pouch against the skin.

Distended bladder on palpation and percussion Pain to suprapubic region, restlessness, frequent small volume voiding, or loss of consciousness Recent anesthesia Recent perineal surgery Presence of perineal swelling Medications Lack of privacy or other factors inhibiting micturition

Retention

The chart describes characteristics of various types of enemas. Which type of enema has the highest risk of complications? Refer to chart.

Tap water

Injury affecting these key areas of nerve conduction, such as ------- or --------- results in intermittent involuntary emptying of the bladder ( select all that apply) a. Immobility b. Cerebral Hemorrhage c. pressure ulcers d. SCI above sacral region

a and d

what disorders affect blood flow to the kidneys? select all that apply a. shock b. osteoarthritis c. hypertension d. heart failure e. carcinoma

a, c, d, heart and circulatory disorders

Although patterns of urination are highly individual, most people void about ---- times a day a. 4-9 b. 5-6 c. 3-7 d. 4-12

b. 5-6

Ingestion of fluids containing caffeine or alcohol Use of diuretics May lead to thirst, dehydration, and weight loss History of diabetes mellitus, diabetes insipidus, or kidney disease

polyuria

Presence of psychologic stress UTI

urgency

The client has a three-way closed continuous catheter 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

The health care provider prescribes a three-way bladder irrigation of normal saline to be infused at a rate of 200 mL per hour, which infused without problem. 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.

250

A --- may obstruct a ureter blocking urine flow from the kidney to the bladder a. kidema b. calculus c. nephritis d. glomeruitis

b. calculus

polyuria is associated with diseases such as? select all that apply a. acute nephritis b. chronic nephritis c. diabetes mellitus d. Parkinsons e. diabetes insipidus

b. chronic nephritis c. diabetes mellitus e. diabetes insipidus

The production of abnormally small amounts of urine by the kidney. a. dysuria b. oliguria c. polyuria d. anuria

b. oliguria less than 500 mL/day or 30 mL/hour for an adult.

The production of abnormally large amounts of urine. Also called diuresis. a. oliguria b. polyuria c. dysuria d. anuria

b. polyuria

stretch receptor stimulation occurs when the adult bladder contains between -----and ----- ml of urine? a. 150 and 325 b. 260 and 510 c. 250 and 450 d. 225 and 535

c. 250 and 450 In children, a considerably smaller volume (50-200 mL)

----- an absence of urine production a. dysuria b. oliguria c. anuria d. polyuria

c. anuria

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. 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 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.

A client has been diagnosed with functional incontinence. Which interventions are 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. Set up schedule of cues such as mealtimes, awakening, and bedtime.

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.

Apply disposable gloves. Lubricate the enema tube and insert it approximately 4 inches. Clamp the tubing if the client expresses discomfort during the procedure. Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

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. The nurse should take which step next?

Insert the catheter 2.5 to 5 cm and inflate the balloon.

Bladder inflammation or associated disease process Difficulties in independent toileting (mobility impairment) Leakage when coughing, laughing, or sneezing Cognitive impairment

incontinence