Urinary and Fecal Elimination

A nurse is caring for a client with a condom catheter. Which of the following is important to implement? Select all that apply. 1. Avoiding kinks in the collection tubing 2. Providing perineal care at least once a day 3. Confirming that the adhesive band is not too tight 4. Leaving 1 inch between the glans penis and drainage tubing 5. Ensuring that the foreskin is over the glans penis before the catheter is applied

1, 2, 3, 4, and 5 Rationale: 1: Avoiding kinking in the tubing is essential so that urine flows unimpeded to the urine collection bag. 2: Perineal hygiene should be performed at once a day, after a bowel movement, and whenever the catheter is changed or replaced. 3: The anchoring device (e.g., adhesive band, elastic strip, or inflatable ring) must be snug enough to prevent the condom from falling off but not so tight that it interferes with blood circulation to the penis. 4: Placing the condom catheter over and beyond the glans penis and leaving 1 inch between the glans penis and drainage tubing prevents pressure against the glans penis that could cause excoriation and skin trauma. 5: The foreskin should be over the glans penis. If the foreskin is left in the retracted position, it can constrict the penis, resulting in edema and tissue injury.

A client is attending the health clinic for treatment of hemorrhoids. The nurse reviews the client's history, interviews the client, and performs a focused assessment. Which of the following in the client's history does the nurse conclude may have influenced the development of the hemorrhoids? Select all that apply. 1. Stands for long periods of time at work 2. Has had multiple pregnancies 3. Tends to have constipation 4. Has a disease of the liver 5. Is obese

1, 2, 3, 4, and 5 Rationale: 1: Prolonged standing or sitting increases pressure on the hemorrhoidal veins that can cause them to become dilated, enlarged, and inflamed. 2: Pregnancy increases intra-abdominal pressure, causing elevated systemic and portal venous pressure, which is transmitted to the anorectal veins. The added pressure of multiple births and having twins aggravates the problem. Eventually, the distended veins separate from the smooth muscle surrounding them, and prolapse of the hemorrhoidal vessels occurs. 3: Repeated straining on defecation because of constipation increases intra-abdominal pressure, eventually causing the anorectal veins to distend and become inflamed, resulting in hemorrhoids. Repeated straining causes them to enlarge. 4: Portal hypertension is associated with diseases of the liver. The veins results in distention and inflammation of the hemorrhoidal veins. 5: Increased intra-abdominal pressure associated with obesity causes elevated systemic and portal venous pressure, which is transmitted to the anorectal veins. Eventually, the veins distend and become inflamed, resulting in hemorrhoids.

During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. 1. Perineal skin irritation 2. Fluid intake of less than 1500 mL/day 3. History of antihistamine intake 4. History of frequent urinary tract infections 5. A fecal impaction

1, 2, 4, and 5 Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 500 mL/day and clients often decreases their intake to try and minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3).

Which nursing diagnosis is/are most applicable to a client with fecal incontinence? Select all that apply. 1. Bowel incontinence 2. Potential for decreased fluid volume 3. Altered body image 4. Social seclusion 5. Potential for developing altered skin integrity

1, 3, 4, and 5 Rationale: Option 1 is the most appropriate. The client is unable to decide when stool evacuation will occur. In option 3, client thoughts about self may be altered if unable to control stool evacuation. In option 4, the client may not feel as comfortable around others. In option 5, increased tissue contact with fecal material may result in impairment. Option 2 is more appropriate for a client with diarrhea. Incontinence is the inability to control feces of normal consistency.

A client is experiencing constipation. Which independent nursing action facilitates defecation of a hard stool? Select all that apply. 1. Applying a lubricant to the anus 2. Providing a site bath after defecation 3. Instilling warm mineral oil into the rectum 4. Placing a warm, wet washcloth against the perineal area 5. Encouraging the client to rocky forward and back while defecating

1, 4, and 5 Rationale: 1: A lubricant reduces friction, which facilitates the passage of a hard, dry stool through the anus. Nurses are legally permitted to diagnose and treat human responses. Constipation is a human response, and applying a water-soluble lubricant to the anus is an independent function of the nurse. 4: A warm, wet washcloth placed against the perineal area may facilitate defecation by relaxing the surrounding muscles and the external sphincter. 5: Rocking forward and back when attempting to defecate increases both tension against the abdomen and intra-abdominal pressure; these facilitate the passage of stool from the rectum and anus.

Which should the nurse implement to facilitate bladder continence for a male client who is cognitively impaired? Select all that apply. 1. Offer toileting reminders every 2 hours 2. Apply a condom catheter in the morning 3. Provide clothing that is easy to manipulate 4. Encourage avoidance of fluids between meals 5. Explain the need to call for help with toileting every 4 hours

1, and 3 Rationale: 1: A cognitively impaired person may not be able to receive, interpret, or respond to cues for voiding. Reminding the person to void every 2 hours results in emptying of the bladder, which may limit episodes of incontinence. 3: Cognitively impaired individuals may have problems handling clothing, particularly when attempting to respond to the urge to void. Clothing that is easy to manipulate, such as articles with elastic waistbands and zippers, will facilitate undressing and dressing to void.

Which statement by a client with diverticulosis alerts the nurse that the client needs additional health teaching? Select all that apply. 1. "I should avoid eating high-fiber cereal." 2. "I sit on the toilet for 10 minutes after breakfast every day." 3. "I am going to drink 8 glasses of water a day when I get home." 4. "I should hold my breath and bear down when having a bowel movement." 5. "I like to massage my lower abdomen when I'm trying to have a bowel movement."

1, and 4 Rationale: 1: High-fiber foods are encouraged because they prevent constipation. Constipation increases intraluminal intestinal pressure, which promotes intestinal mucosal out pouching. Foods low in fiber are prescribed when a client has an acute inflammation of the diverticulum (diverticulitis) until the inflammation resolves. 4: The Valsalva maneuver increased intraluminal intestinal pressure, which promotes intestinal musical outpouching and should be avoided.

A client report burning on urination. Which question should the nurse ask to best obtain information about the client's dysuria? 1. "Can you tell me about the problems you are having with urination?" 2. "How would you describe your experience with incontinence?" 3. "What are your usual bowel habits?" 4. "What color is your urine?"

1. "Can you tell me about the problems you are having with urination?" Rationale: This open-ended question encourages the client to talk about the problem from a personal perspective. Follow-up questions can be more specific.

What is a gastrostomy? 1. An opening through the abdominal wall into the stomach 2. An opening through the abdominal wall into the jejunum 3. An opening into the colon 4. An opening into the ileum

1. An opening through the abdominal wall into the stomach Rationale: A gastrostomy is an opening through the abdominal wall into the stomach. A jejunostomy opens through the abdominal wall into the jejunum. A colostomy opens into the colon (large bowel). A ileostomy opens into the ileum (small bowel).

A nurse is caring for a group of clients with a variety of urinary problems. Which physical response identified by the nurse should cause the most concern? 1. Anuria 2. Dysuria 3. Diuresis 4. Enuresis

1. Anuria Rationale: The inability to produce urine (anuria) is a life-threatening situation. If the cause is not corrected, the client will need dialysis to correct fluid and electrolyte imbalances and rid the body of the waste products of metabolism

A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse instruct the client to perform during the insertion procedure? 1. Bear down 2. Take deep breaths 3. Sip water 4. Tighten the perineum

1. Bear down Rationale: The nurse should instruct the client to bear down as if to void because this relaxes the external sphincter and aids in the insertion procedure. Option 2: It is not necessary for the client to take deep breaths during a catheter insertion. Option 3: It is not necessary for the client to sip water during a catheter insertion. Option 4: It is not necessary for the client to tighten the perineum during catheter insertion.

Clients should be taught that repeatedly ignoring the sensation of needing to defecate could result in which of the following? 1. Constipation 2. Diarrhea 3. Incontinence 4. Hemorrhoids

1. Constipation Rationale: Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result-if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool (option 2). Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence (option 3). Hemorrhoids would occur only if severe drying out of the stool occurs and, thus, repeated need to strain to pass stool (option 4).

Which clinical manifestation can a nurse expect when a postoperative client experiences stress associated with surgery? 1. Decreased urinary output 2. Low specific gravity 3. Reflex incontinence 4. Urinary hesitancy

1. Decreased urinary output Rationale: During surgery, because of the effects of general adaptation syndrome, the posterior pituitary secretes antidiuretic hormone (ADH) that promotes water reabsorption in the kidney tubules. Also, the anterior pituitary secretes adrenocorticotropic hormone that stimulates the adrenal cortex to secrete aldosterone, which reabsorbs sodium and thus water.

A nurse is caring for a client who is experiencing dehydration. Which physiological response to diarrhea should the nurse be most concerned about? 1. Dehydration 2. Malnutrition 3. Excoriated skin 4. Urinary incontinence

1. Dehydration Rationale: Usually digestive juices of 3.5 to 5.0 L are secreted and reabsorbed by the body daily. With diarrhea, the transit time through the intestine is decreased, interfering with the reabsorption of water, resulting in frequent, loose, watery stools and dehydration

A nurse discourages a client from straining excessively when attempting to have a bowel movement. Which undesirable physiological response is the primary reason why straining on defecation should be avoided? 1. Dysrhythmia 2. Incontinence 3. Fecal impaction 4. Rectal hemorrhoid

1. Dysrhythmia Rationale: Straining on defecation requires the person to hold the breath while bearing down (Valsalva maneuver). This maneuver increases the intrathoracic and intracranial pressure, which can precipitate dysrhythmias, brain attack (stroke), and respiratory difficulties; all of these can be life-threatening

Which information about a client is communicated when a nurse documents that the client has polyuria? 1. Excreting excessive amounts of urine 2. Experiencing pain on urination 3. Retaining urine in the bladder 4. Passing blood in the urine

1. Excreting excessive amounts of urine Rationale: Polyuria is an excessive output of urine. This is associated with problems such as diabetes mellitus, diabetes insidious, the acute (diuresis) phase after a burn injury, and reduced levels of ADH.

Which outcome of the options presented is most appropriate for a client with perceived constipation? 1. Have a bowel movement without the use of a laxative 2. Explain the rationale for the use of laxatives 3. Drink 8 glasses of water per day 4. Defecate every day

1. Have a bowel movement without the use of a laxative Rationale: Having a bowel movement without the use of a laxative is the most appropriate outcome for a client with perceived constipation. People with perceived constipation believe that they should have a daily bowel movement and use laxatives, suppositories, enemas, or all of these to achieve this objective.

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? 1. Leaves the catheter in place and gets a new sterile catheter. 2. Leaves the catheter in place and asks another nurse to attempt the procedure. 3. Removes the catheter and redirects it to the urinary meatus. 4. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

1. Leaves the catheter in place and gets a new sterile catheter Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2).

What is oliguria? 1. Low urine output 2. Increased urine output 3. Excessive fluid intake 4. A lack of urine production

1. Low urine output Rationale: Oliguria is a low urine output, usually less than 500 mL a day or 30 mL an hour for an adult. Polyuria (or diuresis) refers to the production of abnormally large amounts of urine by the kidneys, often several liters more than the client's usual daily output. Polydipsia is excessive fluid intake. Anuria refers to a lack of urine production.

A nurse identifies that a client's colostomy stoma is pale. Which should the nurse do? 1. Notify the surgeon 2. Listen for bowel sounds 3. Wash the area with warm water 4. Gently massage around the stoma

1. Notify the surgeon Rationale: A pale stoma indicates that the circulation to the stoma is compromised, and viability of tissue is questionable without immediate intervention. The primary health-care provider should be notified immediately.

A nurse is preparing to administer a cleansing enema to a client who has poor sphincter control. Which of the following actions should the nurse take? 1. Place the client in the dorsal recumbent position on a bedpan. 2. Administer the enema while the client sits on the toilet. 3. Administer an antidiarrheal medication 3 hr prior to the enema. 4. Instill 200 mL of fluid over an hour at 15-min intervals.

1. Place the client in the dorsal recumbent position on a bedpan. Rationale: A client who has poor sphincter control might not be able to retain the enema solution at all. Repositioning the client over the bedpan in the dorsal recumbent position after insertion of the rectal tube will help contain the fluid that is likely to be expelled. Option 2: The angle of insertion of the rectal tube with the client in this position could result in abrasion of the rectal wall. Option 3: An antidiarrheal medication will not correct poor sphincter control and might be counterproductive to the purpose of the enema. Option 4: This would unnecessarily prolong the procedure and would have little or no effect on sphincter control.

A client has urinary incontinence. Which is the best nursing intervention for this client? 1. Providing skin care immediately after soiling 2. Using a deodorant soap when providing skin care 3. Drying the area well after providing perineal area 4. Dusting the perineal area with a light film of cornstarch

1. Providing skin care immediately after soiling Rationale: As soon as possible after an incontinence episode, the client should receive thorough perineal care with soap and water, and the area should be dried well. This action removes urea from the skin, which can contribute to skin breakdown.

A nurse is teaching a client how to irrigate a colostomy. The client asks, "Why is it necessary to use the cone attachment to the irrigation catheter?" What information should the nurse include in a response to this question? 1. Stops enema solution from flowing out of the bowel during the procedure 2. Prevents prolapse of the bowel during evacuation of the solution 3. Dilates the stoma so that the enema tube can be inserted 4. Facilitates the elimination of drainage from the colon

1. Stops enema solution from flowing out of the bowel during the procedure Rationale: The cones advances into the stoma until it effectively fills the opening, which prevents a reflux of solution while the irrigating solution is being instilled. In addition, it helps prevent accidental perforation of the bowel with the rectal catheter.

A confused client is incontinent of urine stool and smears the stool on the bed lines and bed rails. Which should be the initial client goal? 1. The client will be clean and dry continuously 2. The client will become continent within a week 3. The client will stop soiling the environment immediately 4. The client will call for the bedpan whenever the urge to eliminate occurs

1. The client will be clean and dry continuously Rationale: A client's basic physical needs should be given first priority. As soon as a client is incontinent of either urine or stool, the client should receive perineal care. remaining "continuously" clean and dry meets the criterion of a time frame when writing a goal.

A nurse identifies has tarry stools. Which problem should the nurse conclude that the client is experiencing? 1. Upper gastrointestinal bleeding 2. Pancreatic dysfunction 3. Lactulose intolerance 4. Inadequate bile salts

1. Upper gastrointestinal bleeding Rationale: When blood from the bleeding in the upper gastrointestinal tract is exposed to the digestive process, the fecal material becomes black (tarry). In addition, ingestion of exogenous iron, red meat, and dark green vegetables can make the stool look black.

A primary health-care provider prescribes a urine specimen for culture and sensitivity via a straight catheter for a client. Which should the nurse do when collecting this urine specimen? 1. Use a sterile specimen container 2. Collect urine from a catheter port 3. Inflate the balloon with sterile water 4. Have the client void before collecting the specimen

1. Use a sterile specimen container Rationale: A culture attempts to identify the microorganisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against the isolated microorganisms. A sterile specimen container is used to prevent contamination of the specimen by microorganisms outside the body.

A nurse is preparing to administer the first two large volume, cleansing enemas prescribed for a client in preparation for a diagnostic procedure. Which of the following actions should the nurse take? 1. Warm the enema solution prior to instillation. 2. Prepare 1,500 mL of enema fluid. 3. Use tap water as the enema fluid. 4. Hang the enema container 24 inches above the anus.

1. Warm the enema solution prior to instillation. Rationale: It is important to warm the enema solution because cold fluid can cause abdominal cramping. The solution should not be too hot, though, because hot fluid can injure the intestinal mucosa. Option 2: For a large-volume cleaning enema, the recommended amount of fluid to instill for an adult client is 750 to 1,000 mL. Option 3: Tap water is a hypotonic solution that moves fluid from the colon into the interstitial spaces and can cause circulatory overload and electrolyte imbalances. For this reason, tap water enemas cannot be given more than once, and two enemas have been prescribed for this client. Option 4: The height of the fluid container affects the speed of instillation. The maximum recommended height is 18 inches. Hanging the container higher than that can cause rapid instillation and painful distention of the colon.

A nurse is teaching a client with history of constipation about the excessive use of laxatives. Which effect of laxatives should the nurse include as the primary reason why their use should be avoided? 1. Weakens the natural response to defecation 2. Results in distention of the intestines 3. Causes abdominal discomfort 4. Precipitates incontinence

1. Weakens the natural response to defecation Rationale: Laxatives cause a rapid transit time of intestinal contents. When they are used excessively, the bowel's natural responses to intestinal distention and rectal pressure weaken, resulting in chronic constipation.

A nurse is to administer an oil-retention enema, a tap-water enema, and a return-flow enema to three different clients. Which of the following should be performed with all three enemas? Select all that apply. 1. Use between 500 and 1,000 mL of solution 2. Place the client in the left side-lying position 3. Use water-soluble jelly to lubricate the tip of the rectal probe 4. Pull the curtain around the client's bed and drape the client 5. Hold the enema solution a minimum of 12 inches above the anus

2, 3, and 4 Rationale: 2: The left side-lying position allows the fluid to flow via the principle of gravity as the fluid follows the normal curve of the anus, rectum, and sigmoid colon. 3: Lubrication of the tip of the catheter or probe limits trauma to the mucous membranes of the intestine. 4: Enemas require that the client's perineal area be exposed. Pulling the curtain around the client's bed and draping the client provide for client privacy and dignity.

A nurse is caring for a group of clients with gastrointestinal problems. Which of the following can cause both diarrhea and constipation? Select all that apply. 1. Inability to perceive bowel cues 2. Cancer of the large intestine 3. Side effects of medications 4. High-soluble tube feedings 5. Increased metabolic rate

2, and 3 Rationale: 2: Cancer of the large intestine can cause constipation, diarrhea, alternating constipation and diarrhea, or all of these. The mass in the intestinal lumen may partially or totally obstruct the passage of stool, resulting in a condition that appears to be constipation. The leakage of stool around an intestinal tumor/lesion results in a condition that appears to be diarrhea. 3: Medications, depending on their physiological actions, side effects, and toxic effects, can cause either constipation or diarrhea.

Which should a nurse teach the client to avoid that will help prevent urinary diuresis? Select all that apply. 1. Narcotics 2. Caffeine 3. Activity 4. Alcohol 5. Protein

2, and 4 Rationale: 2: Drinks with caffeine (e.g., coffee, tea, and some carbonated beverages) promote the secretion and excretion of increased amounts of urine. This may be related to the inhibition of phosphodiesterase or antagonism of adenosine receptors (or both). Antagonism of adenosine receptors inhibits proximal tubular reabsorption, resulting in an increased urine output. 4: Alcohol limits the production of vasopressin, a hormone that tells the kidneys to reabsorb water. Urine output increases because fluid is not reabsorbed in the kidneys.

A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. 1. Limit fluids to avoid the burning sensation on urination 2. Review symptoms of UTI with the client 3. Wipe the perineal area from back to front 4. Wear cotton underclothes 5. Take baths rather than showers

2, and 4 Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of the area to bacteria (option 5).

Which of the following behaviors indicates that the client on a bladder retraining program has met the expected outcomes? Select all that apply. 1. Voids each time there is an urge 2. Practices slow, deep breathing until the urge decreases 3. Uses adult diapers, for "just in case." 4. Drinks citrus juices and carbonated beverages 5. Performs pelvic floor muscle exercises

2, and 5 Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the best indicator of a successful program 9option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4).

Which statement provides evidence that an older adult who is prone to constipation is in need of further teaching? 1. "I need to drink one and a half to two quarts pf liquid each day." 2. "I need to take a laxative such as milk of magnesia if I don't have a BM every day." 3. "If my bowel pattern changes on its own, I should call you." 4. "Eating my meals at regular times is likely to result in regular bowel movements."

2. "I need to take a laxative such as milk of magnesia if I don't have a BM every day." Rationale: The standard of practice in assisting older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults (option 2). In addition, a normal stool pattern for an older adult may not be daily elimination.

Which client statement supports the nurse's conclusion that a client understands the need to reestablish bowel flora after a week of diarrhea? 1. "I must wean myself off of the antibiotics one day after my temperature is normal." 2. "I should eat a container of yogurt every day for a few days." 3. "I have to add rice to my diet in one meal each day." 4. "I ought to drink eight glasses of water a day."

2. "I should eat a container of yogurt every day for a few days." Rationale: Yogurt is merely milk that is curdled by the addition of bacteria, specifically Lactobacillus bulgaricus and Streptococcus thermopiles. Eating yogurt helps to restore the bacterial balance of the resident flora of the intestine

A nurse is evaluating a client's understanding of healthy defecation. Which of the following statements indicates the need for further teaching? 1. "I will include high-fiber foods, such as vegetables, fruits, and whole grains, in my diet." 2. "I will maintain a fluid intake of 4,000 to 5,000 mL each day." 3. "I will allow time to defecate, preferably at the same time each day." 4. "I will avoid over-the-counter medications to treat constipation and diarrhea."

2. "I will maintain a fluid intake of 4,000 to 5,000 mL each day." Rationale: Client teaching for healthy defecation: maintain fluid intake of 2,000 to 3,000 mL a day; include high-fiber foods, such as vegetables, fruits, and whole grains, in the diet; allow time to defecate, preferably at the same time each day; avoid over-the-counter medications to treat constipation and diarrhea.

The nurse is evaluating a client's understanding of ostomy care. Which of the following client statements indicates a need for further teaching? 1. "The ostomy pouch is emptied when it is one-third to one-half full." 2. "The ostomy pouch can be applied for up to 10 day." 3. "Most ostomy pouches contain odor barrier material." 4. "If the ostomy pouch overfills, it can cause stool to come in contact with the skin."

2. "The ostomy pouch can be applied for up to 10 day." Rationale: Ostomy appliances can be applied for up to 7 days. The pouch is emptied when it is one-third to one-half full. Most pouches contain odor barrier material. if the pouch overfills, it can cause separation of the skin barrier from the skinny and stool can come in contact with the skin.

A nurse is collecting a bowel elimination history from a newly admitted client with a medical diagnosis of possible bowel obstruction. Which question takes priority? 1. "Do you use anything to help you move your bowels?" 2. "When was the last time you moved your bowels?" 3. "What color are your usual bowel movements?" 4. "How often do you have a bowel movement?"

2. "When was the last time you moved your bowels?" Rationale: A cardiac sign of a bowel obstruction is the lack of a bowel movement (obstipation).

You have explained to the client the reason for and steps involved for insertion of an indwelling urinary catheter. List the following actions in the correct sequence: 1. Apply sterile gloves 2. Attach prefilled syringe 3. Secure IUC appropriately to prevent urethral irritation 4. Perform pericare 5. Insert catheter to appropriate length and check urine flow 6. Lubricate catheter 7. Inflate balloon 8. Perform hand hygiene 9. Clean urinary meatus with antiseptic solution 10. Open catheter kit 1. 8, 10, 4, 1, 2, 6, 9, 5, 7, 3 2. 4, 8, 10, 1, 6, 2, 9, 5, 7, 3 3. 4, 8, 1, 10, 6, 2, 9, 5, 7, 3 4. 10, 4, 8, 1, 7, 2, 6, 9, 5, 3

2. 4, 8, 10, 1, 6, 2, 9, 5, 7, 3 Rationale: Option 2 is the correct sequence. Option 1 is incorrect because the nurse needs to perform hand hygiene after pericare. Option 3 is incorrect because the outside of the kit is not sterile and the nurse would would not open the kit with sterile gloves. The current best practice is to not pre-inflate the balloon (option 4).

A client with a new stoma has not had a bowel movement since surgery last week reports feeling nauseous. What is the appropriate nursing action? 1. Prepare to irrigate the colostomy 2. After assessing the stoma and surrounding skin, notify the surgeon 3. Assess bowel sounds and administer antiemetic 4. Administer a bulk-forming laxative, and encourage increased fluids and exercise.

2. After assessing the stoma and surrounding skin, notify the surgeon Rationale: The client has assessment findings consistent with complications of surgery. Option 1: Irrigating the stoma is a dependent nursing action, and is also intervention without appropriate assessment. Option 3: Assessing the peristomal skin area is an independent action, but administering an antiemetic is an intervention without appropriate assessment. Antiemetic are generally ordered to treat immediate postoperative nausea, not several days postoperative. Option 4: Administering a bulk-forming laxative to a nauseated postoperative client is contradicted.

A nurse is evaluating a client's understanding of preventing catheter-associated urinary infections. Which of the following statements indicates a need for further teaching? 1. Maintain a sterile closed-drainage system 2. Always disconnect the catheter and drainage tubing 3. Provide routine perineal hygiene, including cleansing with soap and water after defecation 4. Prevent contamination of the catheter with feces

2. Always disconnect the catheter and drainage tubing Rationale: For preventing catheter-associated urinary infections the following guidelines should be practiced: Do not disconnect the catheter and drainage tubing unless absolutely necessary. Maintain a sterile closed-drainage system. Provide routine perineal hygiene, including cleansing with soap and water after defecation. Prevent contamination of the catheter with feces.

Which of the following actions is NOT appropriate for the nurse removing a fecal impaction? 1. Place a bed pad under the client's buttocks and a bedpan nearby to receive stool. 2. Ask the client to assume a right side-lying position, with the knees flexed and the back toward the nurse. 3. Drape the client for comfort and to avoid unnecessary exposure of the body. 4. Gently insert the index finger into the rectum and move the finger along the length of the rectum

2. Ask the client to assume a right side-lying position, with the knees flexed and the back toward the nurse. Rationale: Ask the client to assume a left side-lying position, with the knees flexed and the back toward the nurse. Place a bed pad under the client's buttocks and a bedpan nearby to receive stool. Drape the client for comfort and to avoid unnecessary exposure to the body. Gently insert the index finger into the rectum and move the finger along the length of the rectum.

Which type of enema is given primarily to expel flatus? 1. Retention 2. Carminative 3. Return-flow 4. Cleansing

2. Carminative Rationale: A carminative enema is given primarily to expel flatus. A retention enema introduces oil or medication into the rectum and sigmoid colon. A return-flow enema is used occasionally to expel flatus. Cleansing enemas may also be described as high or low.

Which action represents the appropriate nursing management of a client wearing an external urinary device? 1. Ensure that the tip of the penis fits snugly against the end of the condom. 2. Check the penis for adequate circulation 30 minutes after applying. 3. Change the condom every 8 hours. 4. Tape the collecting tubing to the lower abdomen

2. Check the penis for adequate circulation 30 minutes after applying. Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight. A 1-in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bag (option 4). An indwelling catheter is secured to the lower abdomen or upper thigh.

A nurse is preparing to remove a client's indwelling urinary catheter. Which of the following actions should the nurse take? 1. Pull the catheter out as quickly as possible. 2. Deflate the balloon completely before removal. 3. Cut the inflation port to deflate the balloon. 4. Tell the client to expect to feel a tugging sensation on removal.

2. Deflate the balloon completely before removal. Rationale: Removing an indwelling urinary catheter while inflation solution remains in the balloon is likely to cause trauma to the urethral canal. Therefore, the nurse should deflate the balloon completely prior to removing an indwelling urinary catheter. Option 1: The nurse should use a slow, steady motion when removing an indwelling urinary catheter. Option 3: The inflation port should never be cut. Option 4: The client should not expect to feel a tugging sensation during the removal of an indwelling urinary catheter because this could indicate resistance due to a still partially inflated port. However, it is common for clients to feel a burning sensation as a urinary catheter is removed.

Which action is important for the nurse to teach clients about the intake of bran to facilitate defecation? 1. Ingest 3 tablespoons of bran each morning 2. Drink at least 8 glasses of fluids daily when taking bran 3. Attempt a bowel movement right after ingesting the bran 4. Take a cathartic daily that will supplement that action of brain

2. Drink at least 8 glasses of fluids daily when taking bran Rationale: Bran is an insoluble fiber that increases bulk in the intestines. Eight glasses of water daily keep the body well hydrated and the stool soft. Intestinal elimination is dependent on the relationships among fiber, water, and activity.

A client has a urinary retention catheter. Which is the most important when the nurse cares for this client? 1. Applying an antimicrobial agent to the urinary meatus 2 times a day 2. Ensuring that the catheter remains connected to the collection bag 3. Wearing sterile gloves when accessing the specimen port 4. Increasing fluid intake to 3,000 mL a day

2. Ensuring that the catheter remains connected to the collection bag Rationale: Maintaining the connection of the catheter to the collection bag prevents the introduction of microorganisms that can cause infection. A urinary retention catheter is a closed system that should remain closed.

A nurse must measure the intake and output (I&O) of a client who has a urinary retention catheter. Which equipment is most appropriate to use to measure urine output from a urinary retention catheter accurately? 1. Urinal 2. Graduate 3. Large syringe 4. Urine collection bag

2. Graduate Rationale: A graduate is a collection container with volume marking (usually at 25 mL increments) that promote accurate measurements of urine volume.

A primary care provider orders examination of stool for signs of intestinal infection. What color of stool would the nurse expect to see? 1. Red 2. Green 3. Black 4. White

2. Green Rationale: Orange or green-colored stools are indications of an intestinal infection. Additional abnormal colors to stool include: Adult: brown, clay, or white, absence of bile pigment (bile obstruction); diagnostic study using barium Infant: yellow, or black or tarry drug (e.g., iron); bleeding from upper gastrointestinal tract (e.g., stomach, small intestine); diet high in red meat and dark green vegetables (e.g., spinach) Red, bleeding from lower gastrointestinal tract (e.g., rectum); some foods (e.g., beets) White, malabsorption of fats; diet high in milk products and low in meat

A nurse determines that the teaching about a guaiac test of stool is understood when the client states that it identifies the prescence of which of the following? 1. Ova and parasites 2. Hidden blood 3. Bacteria 4. Bile

2. Hidden blood Rationale: Testing the feces for occult blood is called the guaiac test. This test uses a chemical reagent to detect the presence of the enzyme peroxidase in the hemoglobin molecule. Occult blood is obscure (hidden) and may not be visible to the naked eye.

A nurse performs a physical assessment of a newly admitted client who is incontinent of stool. For which characteristic related to bowel incontinence should the nurse assess the client? 1. Frequent, soft stools 2. Involuntary passage of stool 3. Impaired anal sphincter control 4. Greenish-yellow color to the stool

2. Involuntary passage of stool Rationale: An involuntary passage of stool is a major clinical finding associated with bowel incontinence, which is the state in which an individual experiences a change in usual bowel habits characterized by involuntary passage of stool.

Which word is specific regarding how a soapsuds enema works on the mucosa of the bowel? 1. Dilating 2. Irritating 3. Softening 4. Lubricating

2. Irritating Rationale: Although a soapsuds enema works by increasing the volume in the colon, its unique attribute is that soap is irritating to the intestinal mucosa. Irritation of the mucosa precipitates peristalsis, which facilitates the evacuation of fecal material.

The nurse will need to assess the client's performance of clean intermittent catheterization (CIC) for a client with which urinary diversion? 1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy

2. Kock pouch Rationale: The ideal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3).

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? 1. Grasp the penis at its base. 2. Lift the penis perpendicular to the body. 3. Hold the penis parallel to the client's body. 4. Lift the penis to a 45° angle to the client's body.

2. Lift the penis perpendicular to the body. Rationale: Lifting the penis to a position perpendicular to the body, or at a 90° angle, while applying light traction straightens the urethral canal to facilitate catheter insertion. Option 1: Grasping the penis at its base does not effectively straighten the urethral canal to ease catheter insertion. Option 3: Holding the penis parallel to the client's body does not effectively straighten the urethral canal to ease catheter insertion. Option 4: Lifting the penis to a 45° angle to the client's body does not effectively straighten the urethral canal to ease catheter insertion.

A nurse is caring for two clients. One client has reflex incontinence and the other has total incontinence. Which characteristic is common to both reflex incontinence and total incontinence? 1. Small loss of urine after an increase in intra-abdominal pressure 2. Loss of urine without awareness of bladder fullness 3. Retention of urine with intermittent urine flow 4. Strong, sudden desire to pass urine

2. Loss of urine without awareness of bladder fullness Rationale: Involuntary voiding and a lack of awareness of bladder distention are related directly to both reflex incontinence and total incontinence. Reflex incontinence is the predictable, involuntary loss of urine with no sensation of urgency, the need to void, or bladder fullness. Total incontinence is the continuous unpredictable loss of urine without distention or awareness of bladder fullness

A nurse is administering a return-flow enema to a client. After instilling 100 mL of enema fluid, which of the following actions should the nurse take? 1. Instruct the client to retain the fluid. 2. Lower the container to allow the solution to flow back out. 3. Help the client to the toilet or bedside commode. 4. Wait 5 min and instill another 100 mL of fluid.

2. Lower the container to allow the solution to flow back out. Rationale: Return-flow enemas involve moving 100 to 200 mL of fluid into and out of the rectum. After instilling the solution, the nurse lowers the container to allow the solution to flow back into the container and then repeats the process several times. Option 1: Having the client retain the fluid is appropriate for a retention enema, not for a return-flow enema. Option 3: Assisting the client to the toilet or commode or providing a bedpan is appropriate for a cleansing enema, not for a return-flow enema. Option 4: This is inappropriate during the administration of a return-flow enema.

Which clinical manifestation identified by the nurse commonly is associated with excessive production of antidiuretic hormone (ADH)? 1. Diuresis 2. Oliguria 3. Retention 4. Incontinence

2. Oliguria Rationale: ADH increases the reabsorption of water by the kidney tubules, thus decreasing the amount of urine formed. Oliguria is diminished urinary output relative to intake (less than 400 mL in 24 hours)

A school nurse us planning a health class about bodily functions. Which information should be included regarding the purpose of mucus in the gastrointestinal tract? 1. Activates digestive enzymes 2. Protects the gastric mucosa 3. Enhances gastric acidity 4. Emulsifies fats

2. Protects the gastric mucosa Rationale: Mucus secreted by mucus membranes and glands is a viscous, slippery fluid containing mucin, white blood cells, water, inorganic salts, and exfoliated cells. Mucin, a mucopolysaccharide, is a lubricant that protects body surfaces from friction and erosion.

A nurse reviews the results of a client's urinalysis. Which constituent found in urine indicates the presence of an abnormality that should be reported to the primary health-care provider? 1. Electrolytes 2. Protein 3. Water 4. Urea

2. Protein Rationale: The presence of protein in the urine indicates that the glomeruli have become too permeable, which occurs with kidney disease. Most plasma proteins are too large to move out of the glomeruli, and the small proteins that enter the filtrate are reabsorbed by pinocytosis.

A client who is postoperative is experiencing abdominal distention and is having difficulty expelling flatus. the nurse should expect the provider to prescribe which of the following types of enemas? 1. Cleansing 2. Return-flow 3. Medicated 4. Oil-retention

2. Return-flow Rationale: Return-flow, or flush, enemas are used to expel flatus, stimulate peristalsis, and relieve abdominal distention. Option 1: Cleansing enemas remove feces when a client is constipated, has a fecal impaction, or is undergoing preparation for surgery or diagnostic procedures. This type of enema would not address this client's immediate need. Option 3: Medicated enemas are given for a variety of reasons, such as to reduce bacteria in the colon prior to surgery or to exert a systemic effect. This type of enema would not address the client's immediate need. Option 4: Oil-retention enemas lubricate the rectum and the colon, making feces softer and easier to pass. This type of enema would not address the client's immediate need.

Which goal us the most appropriate for clients with diarrhea related to ingestion of an antibiotic for an upper respiratory infection? 1. The client will wear a medical alert bracelet for antibiotic allergy. 2. The client will return to his or her previous fecal elimination pattern 3. The client will verbalize the need to take an antidiarrheal medication prn 4. The client will increase intake of insoluble fiber such as grains, rice, and cereals

2. The client will return to his or her previous fecal elimination pattern Rationale: Once the cause of diarrhea has been identified and corrected, the client should return to his or her previous elimination pattern. This is not an example of an allergy to the antibiotic but a common consequence of over-growth of bowel organisms not killed by the drug (option 1). Antidiarrheal medications are usually prescribed according to the number of stools, not routinely around the clock (option 3). Increasing intake of soluble fiber such as oatmeal or potatoes may help absorb excess liquid and decrease the diarrhea, but insoluble fiber will not (option 4).

A client's urine is cloudy, is amber, and has an unpleasant odor. Which problem may this information indicate that requires the nurse to make a focused assessment? 1. Urinary retention 2. Urinary tract infection 3. Ketone bodies in the urine 4. High urinary calcium level

2. Urinary tract infection Rationale: The urine appears concentrated (amber) and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria)

What is urinary frequency? 1. Voiding two or more times at night 2. Voiding at frequent intervals 3. The sudden and strong desire to void 4. Voiding that is either painful or difficult

2. Voiding at frequent intervals Rationale: Urinary frequency is voiding at frequent intervals, that is, more than four to six times per day. Nocturne is voiding two or more times at night. Urgency is the sudden strong desire to void. Dysuria means voiding that is either painful or difficult.

A nurse should use a fracture bedpan for clients with which condition? Select all that apply. 1. Below the knee amputation 2. Peripheral vascular disease 3. Spinal cord injury 4. Dementia 5. Obesity

3 Rationale: A fracture bedpan has a low back that promotes functional alignment of the client's lower back while on the bedpan.

A nurse must obtain a urine specimen for a culture and sensitivity test from a client who has an indwelling urinary catheter. Place the following steps in the order in which they should be performed? 1. Wash your hands and don clean gloves 2. Remove the clamp from the drainage tubing 3. Drain the urine in the tubing into the drainage bag 4. Clamp the drainage tubing below the specimen port for 15 to 30 minutes 5. Swab the specimen port with an antiseptic and aspirate urine via a sterile syringe 6. Transfer the urine to a sterile specimen cup and discard the syringe into the sharps container

3, 4, 1, 5, 6, 2 Rationale: 3: Draining the urine ensures that previously produced urine is not collected for a correct specimen. 4: Clamping the drainage tubing allows urine to collect above the specimen port. 1: Washing the hands limits the number of microorganisms on the hands. Clean gloves protect the nurse from the client's body fluids. Both practices are part of standard precautions. 5: The use of an antiseptic swab removes microorganisms on the specimen port, and sterile equipment maintains the sterility of the closed urinary drainage system. 6: The sterility of the specimen must be maintained to prevent contamination of the specimen, which can result in inaccurate results. Discarding the used syringe in a sharps container prevents accident; injury to self or others. 2: Removing the clamp from the drainage tubing reestablishes the flow of urine from the client to the drainage bag. If it is left clamped, urine will not drain, causing bladder distention, and may precipitate a stasis-induced urinary tract infections.

A nurse is assisting a client with a regular bedpan. Which nursing action is essential? Select all that apply. 1. Position the client slightly pff the back edge of the bedpan 2. Fold the top linen out of the way when putting the client on the bedpan 3. Remain outside the curtains of the bed until the client is done using the bedpan 4. Elevate the head of the bed to the Fowler position after the client is on the bedpan 5. Raise the side rails on both sides of the bed after the client is positioned on the bedpan

3, 4, and 5 Rationale: 3: Remaining outside the curtains of the client's bed while the client is on the bedpan allows the nurse to be in close proximity to the client. the nurse is available to assist the client is needed, and it provides a sense of security for the client. 4: Elevating the head of the bed so that the client is in high-Fowler position assumes the familiar, usual position for having a bowel movement. A vertical position utilizes gravity, and hip flexion raises intra-abdominal pressure, both of which maximize evacuation of feces. 5: Raising both side rails provides support on which the client can rest the upper extremities and maintains client safety. Raising the side rails before raising the head of the bed maintains safety.

When the nurse is planning nursing care, which factor in the client's history places the client at risk for stress incontinence? Select all that apply. 1. Lumbar spinal cord injury 2. Urinary obstruction 3. Six vaginal births 4. Menopause 5. Obesity

3, 4, and 5 Rationale: 3: Stress incontinence is an immediate involuntary loss of urine during an increase in intra-abdominal pressure. It is associated with weak pelvic muscles and structural supports resulting from multiple pregnancies, age-related degenerative changes, and over distention between voiding. 4: Older women experience a weakening of the muscles surrounding the urinary and reproductive symptoms because of decreasing levels of estrogen associated with menopause. 5: The relationship of obesity and stress incontinence is theorized to be that excess weight increases abdominal pressure. This, in turn, increases bladder pressure and mobility of the urethra. In addition, obesity may lead to chronic strain, stretching, and weakening of the nerves and muscles of the pelvic area.

Which statement by a client with an ileostomy alerts the nurse to the need for further education? 1. "I don't expect to have much of a problem with fecal odor from the stoma." 2. "I will have to take special precautions to protect my skin around the stoma." 3. "I am going to have a bowel movement every morning when I irrigate the stoma." 4. "I should avoid gas-forming foods like beans to limit funny noises from the stoma."

3. "I am going to have a bowel movement every morning when I irrigate the stoma." Rationale: This statement is inaccurate in relation to an ileostomy and indicates that the client needs more teaching. An ileostomy produces liquid fecal drainage, not formed stool requires irrigation.

A primary health-care provider prescribes a tap-water enema for a client. The client asks about the purpose of the enema. Which specific information about the purpose of a tap-water enema should be included in the nurse's response? 1. "It reduces abdominal gas." 2. "It drains the urinary bladder." 3. "It empties the bowel of stool." 4. "It limits nausea and vomiting."

3. "It empties the bowel of stool." Rationale: A tap-water enema instills fluid into the large intestines; the pressure of this volume stimulates peristalsis, causing the colon to evacuate stool.

A nurse is testing urine for specific gravity. Which of the following would be considered a normal range for the test result? 1. 0.100 to 0.999 2. 1.000 to 1.050 3. 1.010 to 1.025 4. 1.050 to 1.100

3. 1.010 to 1.025 Rationale: Normal results for a urine specific gravity should be in the range of 1.010 to 1.025. All other results not in this range are considered abnormal.

A nurse is administering an enema medicated with sodium polystyrene sulfonate to an adult client who has hyperkalemia. To which of the following lengths should the nurse insert the rectal tube? 1. 2.5 cm to 3.75 cm (1 to 1.5 in) 2. 5 cm to 7.5 cm (2 to 3 in) 3. 7.5 cm to 10 cm (3 to 4 in) 4. 10 cm to 12.5 cm (4 to 5 in)

3. 7.5 cm to 10 cm (3 to 4 in) Rationale: This is the appropriate length of insertion for an adult client. Option 1: This is the appropriate length of insertion for an infant, rather than an adult. Option 2: This is the appropriate length of insertion for a child, rather than an adult. Option 4: This length of insertion puts the client at risk for bowel perforation.

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catheterization? 1. A client who has a persistent urinary tract infection. 2. A client who has urge incontinence. 3. A client who is in the ICU for a gastrointestinal bleed. 4. A client who has incontinence due to cognitive decline.

3. A client who is in the ICU for a gastrointestinal bleed. Rationale: The nurse should expect a prescription for urinary catheterization for this client because precise measurement of urinary output is crucial for managing fluid balance in clients who are critically ill. Option 1: Urinary tract infections are treated with antimicrobial agents, increased fluid intake, and pain management. Therefore, the nurse should not expect a prescription for urinary catheterization for a client who has a persistent urinary tract infection. Option 2: Treatment options for urge incontinence typically include pelvic floor exercises, medications, and bladder retraining. Therefore, the nurse should not expect a prescription for urinary catheterization for a client who has urge incontinence. Option 4: Incontinence due to cognitive decline is a type of functional incontinence that is typically treated with scheduled toileting and absorbent adult briefs. Urinary catheterization might be necessary as a last resort for a client who has incontinence due to cognitive decline. However, as this client is newly admitted, the nurse should not expect a prescription for urinary catheterization.

The nurse is promoting regular defecation for a client whom she is taking care of. Which of the following actions by the nurse is NOT correct? 1. A client should be encourage to defecate when the urge is recognized. 2. Regular exercise helps clients develop a regular defecation pattern. 3. Although the squatting position best facilitates defecation, the best position for most clients seems to be leaning backward while on a toilet seat. 4. For clients who have difficulty sitting down and getting up from the toilet, an elevated toilet seat can be attached to a regular toilet seat.

3. Although the squatting position best facilitates defecation, the best position for most clients seems to be leaning backward while on a toilet seat. Rationale: Although the squatting position best facilitates defecation, the best position for most clients seems to be leaning forward while on a toilet seat. A client should be encouraged to defecate when the urge is recognized. Regular exercise helps clients develop a regular defecation pattern. For clients who have difficulty sitting down and getting up from the toilet, an elevated toilet seat can be attached to a regular toilet seat.

Which focus is the nurse most likely to teach for a client with a flaccid bladder? 1. Habit training: attempt voiding at specific time periods. 2. Bladder training: delay voiding according to a preschedule timetable. 3. Credé's maneuver: apply gentle manual pressure to the lower abdomen. 4. Kegel exercises: contract the pelvic muscles.

3. Credé's maneuver: apply gentle manual pressure to the lower abdomen. Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic floor muscles.

Which of the following is an abnormal color or clarity of urine? 1. Straw 2. Amber 3. Dark amber 4. Transparent

3. Dark amber Rationale: The normal color or clarity of urine is straw, amber, or transparent. Abnormal color or clarity of urine is dark amber, dark orange, red, dark brown, cloudy, mucous plugs, viscid, thick.

During discharge planning, the nurse is teaching the client how to perform pelvic muscle exercises (Kegels). Which of the following actions is correct? 1. Initially perform each contraction 10 times, five times daily. Gradually increase the count to a full 10 seconds for both contraction and relaxation. 2. To control episodes of stress incontinence, perform a pelvic muscle contraction only after activities that increase intra-abdominal pressure, such as coughing, laughing, sneezing, or lifting. 3. Develop a schedule that will help remind you to do these exercises, fore maple, before getting put of bed in the morning. 4. Contract your pelvic muscles whereby you pull your rectum, urethra, and vagina up inside, and hold for a count of 1 to 2 seconds. Then relax the same muscles for count of 1 to 2 seconds.

3. Develop a schedule that will help remind you to do these exercises, fore maple, before getting put of bed in the morning. Rationale: Develop a schedule that will help remind you to do these exercises, for example, before getting out of bed in the morning. Initially perform each contraction 10 times, three times daily. Gradually increase the count to a full 10 seconds for both contraction and relaxation. To control episodes of stress incontinence, perform a pelvic muscle contraction when initiating any activity that increases intra-abdominal pressure, such as coughing, laughing, sneezing, or lifting. Contract your pelvic muscles whereby you pull your rectum, urethra, and vagina up inside, and hold for a count of 3 to 5 seconds. Then relax the same muscles for a count of 3 to 5 seconds.

A nurse is caring for a group of clients. Which client factor should the nurse identify as placing a client at risk for bowel incontinence? 1. Being ninety years old 2. Taking a sedative for sleep 3. Disoriented to time, place, and person 4. Receiving multiple antibiotic medications

3. Disoriented to time, place, and person Rationale: When a person is disoriented to time, place, and person, the individual may not have the cognitive ability to perceive and interpret intestinal distention and rectal pressure cues to defecate, resulting in bowel incontinence.

A nurse is performing a physical assessment on a newly admitted client who us experiencing urinary incontinence. Which problem identified by the nurse is often associated with this problem? 1. Chronic pain 2. Reduced fluid intake 3. Disturbed self-esteem 4. Insufficient knowledge

3. Disturbed self-esteem Rationale: Disturbed self-esteem is the state in which an individual experiences, or is at risk of experiencing, negative self-evaluation about self or capabilities. Incontinence may be viewed by a client as regressing to childlike behavior and has a negative impact on feelings about the self.

A nurse is evaluating a class on facilitating and promoting urinary elimination recognizes that further teaching is necessary when which of the following statements is made by the participant? 1. Advise the client and family to install grab bars and elevated toilet seats as needed 2. Teach the client to empty the bladder completely at each voiding 3. Emphasize the importance of drinking five to six 8-ounce glasses of water daily 4. Suggest clothing that is easily removed for toileting, such as elastic-waist pants with Velcro closures

3. Emphasize the importance of drinking five to six 8-ounce glasses of water daily Rationale: Facilitating and promoting urinary elimination includes the following: Emphasize the importance of drinking eight to ten 8-ounce glasses of water daily. Advise the client and family to install grab bars and elevated toilet seats as needed. Teach the client to empty the bladder completely at each voiding. Suggest clothing that is easily removed for ticketing, such as elastic-waist pants or pants with Velcro closures.

The nurse is performing urethral catheterization on a male client. Which of the following actions by the nurse is correct? 1. Lubricates the catheter 1 to 2 inches 2. Picks up a cleansing ball with the forceps in the non dominant hand and wipes from the top of the meatus in a circular motion around the glans. 3. Grasps the catheter firmly 2 to 3 inches from the tip; asks the client to take a slow deep breath and inserts the catheter as the client exhales. 4. Puts on examination gloves

3. Grasps the catheter firmly 2 to 3 inches from the tip; asks the client to take a slow deep breath and inserts the catheter as the client exhales. Rationale: Lubricate the catheter 6 to 7 inches for males. if this is not done, the entire part of the catheter that is inserted into the make penis will not be lubricated. This will make the procedure very uncomfortable for the client as well cause harm to the client. The following statements are correct: Pick up a cleansing ball with forceps in your dominant hand and wipe from the center of the meatus in a circular motion around the glans. Grasp the catheter firmly 2 to 3 in. from the tip. Ask the client to take a slow deep breath and insert the catheter as the client exhales.

During discharge planning, the nurse is teaching the client how to manage diarrhea. Which of the following actions is NOT correct? 1. Drink at least eight glasses of water per day to prevent dehydration 2. Eat foods with sodium and potassium 3. Increase foods containing insoluble fiber, such as high-fiber whole-wheat bread 4. Limit fatty foods

3. Increase foods containing insoluble fiber, such as high-fiber whole-wheat bread Rationale: Limit foods containing insoluble fiber, such as high-fiber whole-wheat and whole-grain breads and cereals, and raw fruits and vegetables. Drink at least eight glasses of water per day to prevent dehydration. Eat foods with sodium and potassium. Limit fatty foods.

A nurse is evaluating a nursing student's understanding of the actions of enema solutions. Which of the following statements demonstrates a need for further teaching? 1. Hypertonic solutions draw water into the colon 2. Hypotonic solutions distend the colon, stimulate peristalsis's and soften feces 3. Isotonic solutions lubricate the feces and colonic mucosa 4. Soapsuds solutions irritate the mucosa and distend the colon

3. Isotonic solutions lubricate the feces and colonic mucosa Rationale: Oil solutions lubricate the feces and the colonic mucosa. Isotonic solution distend the colon, stimulate peristalsis and soften feces. Hypertonic solutions draw water into the colon. Hypotonic solutions distend the colon, stimulate peristalsis, and soften feces. Soapsuds solution irritate the mucosa and distend the colon.

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? 1. Stretch the sheath portion of the condom catheter along the length of the penis. 2. Secure the sheath portion with adhesive tape. 3. Leave a space between the penis and sheath portion tip. 4. Reposition the foreskin after application.

3. Leave a space between the penis and sheath portion tip. Rationale: The nurse should leave a space of 2.5 to 5 cm (1 to 2 in) between the tip of the penis and the end of the catheter. This space helps prevent irritation of the tip of the penis and allows full drainage of urine. Option 1: The nurse should roll the condom catheter smoothly over the length of the penis, rather than stretch the condom along the length of the penis. Option 2: Adhesive tape is painful to remove and it will not expand with size changes of the client's penis, which could cause impaired blood flow. Therefore, it should not be used to keep a condom catheter in place. Option 4: Manipulation of the foreskin is not required during the application of a condom catheter.

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? 1. Measure the client's vital signs. 2. Notify the primary care provider. 3. Lower the enema fluid container. 4. Stop the enema instillation.

3. Lower the enema fluid container. Rationale: Some abdominal cramping is to be expected during enema administration. To ease the client's discomfort, the nurse should slow the rate of instillation by reducing the height of the enema fluid container. Option 1: This assessment will not relieve the client's discomfort. Option 2: This intervention will not relieve the client's discomfort. Option 4: Discontinuing the enema is indicated if the client's abdomen becomes rigid and distended or if there is evidence of bleeding.

An older adult with an indwelling urinary catheter is receiving 75 mL of 0.9% sodium chloride hourly. The client has had several hospital admissions in the last year for dehydration. The nurse is concerned about the client's renal function. What is the best intervention by the nurse to assess this client's renal functioning? 1. Inspect the client's dependent areas for signs of edema 2. Calculate the client's intake and output every shift 3. Monitor the client's urine output hourly 4. Obtain the client's weight daily

3. Monitor the client's urine output hourly Rationale: The kidneys should produce more than 30 mL/hour. The client has an indwelling urinary catheter that facilitates the assessment of urine output hourly. Clients without an indwelling urinary catheter should void a minimum of 240 mL or urine in 8 hours.

A nurse is caring for a debilitated female client with nocturia. Which nursing intervention is the priority when planning to meet this client's needs? 1. Encouraging the use of bladder training exercises 2. Providing assistance with toileting every 4 hours 3. Positioning a bedside commode near the bed 4. Teaching the avoidance of fluids after 5 p.m

3. Positioning a bedside commode near the bed Rationale: The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on a commode uses gravity to empty the bladder fully and thus prevents urinary stasis.

A nurse identifies that the client has overflow incontinence. Which factor contributes to this clinical manifestation? 1. Coughing 2. Mobility deficits 3. Prostate enlargement 4. Urinary tract infections

3. Prostate enlargement Rationale: An enlarged prostate compresses the urethra and interferes with the overflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urethral sphincter temporarily (25 to 60 mL) of urine to escape (overflow incontinence).

The nurse assess a client's abdomen several days after abdominal surgery. It is firm, distended, and painful to palpate. The client reports feeling "bloated." The nurse consults with the surgeon, who orders an enema. The nurse prepares to give what kind of enema? 1. Soapsuds 2. Retention 3. Return flow 4. Oil retention

3. Return flow Rationale: This provides relief of postoperative flatus, stimulating bowel mobility. Options 1, 2, and 4 manage constipation and do not provide flatus relief.

A nurse is caring for a client with an intestinal stoma. Which intervention is most important? 1. Cleansing the stoma with cool water 2. Spraying an air-freshening deodorant in the room 3. Selecting a bag with an appropriate-size stomal opening 4. Wearing sterile, non latex gloves when caring for the stoma

3. Selecting a bag with an appropriate-size stomal opening Rationale: The opening of the appliance must be large enough to encircle the stoma to within 1/8 inch to protect the surrounding tissue from the enzymes present in the intestinal discharge without impinging on the stoma. Pressure against the stoma can damage delicate mucosal tissue or impede circulation to the stoma, both of which can impair the viability of the stoma.

Which of the following is most likely to validate that a client is experiencing intestinal bleeding? 1. Large quantities of fat mixed with pale yellow liquid stool 2. Brown, formed stools 3. Semisoft black-colored stools 4. Narrow, pencil-shaped stools

3. Semisoft black-colored stools Rationale: Blood in the upper GI tract is black and tarry. Option 1 can be a sign of malabsorption in an infant, option 2 is normal stool, and option 4 is characteristic of an obstructive condition of the rectum.

Which assessment is not related to monitoring both urine and stool? 1. Constituents 2. Urgency 3. Shape 4. Color

3. Shape Rationale: Only stool can be assessed regarding shape. Stool usually is tubular in shape. Urine is a liquid that assumes the shape of the container in which is it collected.

A nurse is inserting an indwelling urinary catheter into a male client. the nurse feels firm resistance while inserting the urinary catheter through the penis. What should the nurse do? 1. Lower the penis until it is parallel to the length of the body 2. Inflate the balloon of the catheter with 10 mL of normal saline 3. Stop the procedure and notify the health-care provider about the resistance 4. Use a twisting motion and firmly advance the catheter 2 inches farther into the penis

3. Stop the procedure and notify the health-care provider about the resistance Rationale: Resistance indicates that there may be a blockage in the urethra (e.g., enlarged prostate, tumor). The procedure should be discontinues when firm resistance is felt, to prevent trauma to the urinary system. The event should be documented in the client's clinical record and the primary health-care provider notified.

The nurse is likely to report which finding to the primary care provider for a client who has an established colostomy? 1. The stoma extends 1/2 in. above the abdomen 2. The skin under the appliance looks red briefly after removing the appliance 3. The stoma is a deep red-purple 4. The ascending colostomy delivers liquid feces

3. The stoma is a deep red-purple Rationale: An established stoma should be dark pink like the color of the buccal mucosa and is slightly raised above the abdomen. The skin under the appliance may remain pink or red for a while after the adhesive is pulled off. feces from an ascending ostomy are very liquid, less so from a transverse ostomy, and more solid from a descending or sigmoid stoma.

A client is admitted to the emergency department because of hypertension and oliguria. For which additional clinical manifestation associated with this cluster of information should the nurse assess the client? 1. Thirst 2. Retention 3. Weight gain 4. Urinary hesitancy

3. Weight gain Rationale: Oliguria is the inability to produce more than 400 to 500 mL of urine daily. Expected daily urinary output is 1,000 to 3,000 mL, depending on the volume of fluid intake. If urine is not being produced in the presence of an average daily intake of 2,500 mL of fluid, then fluid will be retained and reflected in a gain in weight. One liter of fluid weighs 2.2 pounds. Excess fluid contributes to an increase in circulating blood volume, causing hypertension.

When a nurse assesses a client, which clinical manifestations support the presence of urinary retention? Select all that apply. 1. Nocturia 2. Hematuria 3. Bladder contractions 4. Suprapubic distention 5. Frequent small voiding

4, and 5 Rationale: 4: The bladder lies in the pelvic cavity behind the symphysis pubis. When it fills with urine (600 mL), the bladder extends above the symphysis pubis, and when greatly distended (2,000 to 3,000 mL), it can reach to the umbilicus. 5: With urinary retention, the bladder fills with urine, causing distention. Eventually, the external urethral sphincter temporarily opens to allow a small volume of urine to pass out of the bladder (overflow incontinence, retention with overflow).

A nurse is evaluating a nursing student's understanding of colostomies. Which of the following statements demonstrates a need for further teaching? 1. "The single stoma is created when one end of bowel is brought out through an opening onto the anterior abdominal wall." 2. "With a loop colostomy, a loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge, or a piece of rubber tubing." 3. "The divided colostomy consists of two edges of bowel brought out onto the abdomen but separated from each other." 4. "The loop colostomy is often used in situations where spillage of feces into the distal end of the bowel needs to be avoided."

4. "The loop colostomy is often used in situations where spillage of feces into the distal end of the bowel needs to be avoided." Rationale: The divided colostomy is often used in situations where spillage of feces into the distal end of the bowel needs to be avoided. The single stoma is created when one end of bowel is brought out through an opening onto the anterior abdominal wall. In the loop colostomy, a loop of bowel is brought out onto the abdominal wall and supported by a plastic bridge, or a piece of rubber tubing. The divided colostomy consists of two edges of bowel brought out onto the abdomen but separated from each other.

A nurse is providing perineal care for a female client who has an indwelling urinary catheter. Which of the following areas should the nurse cleanse last? 1. Urethral meatus 2. Labia minora 3. Perineum 4. Anus

4. Anus Rationale: The nurse should identify that the basic aseptic principle applicable to perineal care is to cleanse from the area that is least contaminated to the area that is the most contaminated. The anal area is typically contaminated with coliform bacteria and should therefore be cleansed last. Option 1: The nurse should cleanse from meatus toward the anus to minimize fecal contamination of the urinary and reproductive systems. Option 2: The nurse should not cleanse the labia minora last because this would violate a basic principle of asepsis. Option 3: The nurse should not cleanse the perineum last because this would violate a basic principle of asepsis.

A nurse is preparing to administer an oil retention enema to a client who has constipation. the nurse should instruct the client to retain the solution for which of the following durations? 1. The duration of the procedure 2. 10 to 15 min 3. Until the client feels the urge to defecate 4. At least 30 min

4. At least 30 min Rationale: The enema will be most effective in softening the stool and lubricating its passageway if the client retains the oil for a minimum of 30 min. Option 1: This might be enough time to lubricate the rectum and the distal portion of the colon, but it is not enough time to allow the oil to penetrate the feces and soften them to facilitate elimination. Option 2: This might be enough time to lubricate the rectum and the distal portion of the colon, but it is not enough time to allow the oil to penetrate the feces and soften them to facilitate elimination. Option 3: This instruction is too vague to ensure the effectiveness of the enema. The client might feel an immediate need to defecate, which might result in straining because the oil has not had enough time to penetrate and soften the feces for easy elimination.

During discharge planning, the nurse is teaching the client ways to prevent a recurrence of a UTI. Which of the following actions is correct? 1. Drink six 6-ounce glasses of water per day to flush bacteria out of the urinary system 2. Wear nylon rather than cotton underclothes 3. Girls and women should always wipe the perineal area from back to front following urination of defecation in order to prevent introduction of gastrointestinal bacteria into the urethra 4. Avoid tight-fitting pants or other clothing that can irritate the urethra and prevents ventilation of the perineal area

4. Avoid tight-fitting pants or other clothing that can irritate the urethra and prevents ventilation of the perineal area Rationale: Ways to prevent a recurrence of a UTI include the following: Avoid tight-fitting pants or other clothing that creates irritation to the urethra and prevents ventilation of the perineal area. Drink eight 8-ounce glasses of water per day to flush bacteria out of the urinary system. Wear cotton rather than nylon clothing. Girls and women should always wipe perineal area from front to back following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra.

A client is admitted with lower gastrointestinal tract bleeding. Which characteristic of the client's stool should the nurse assess for that supports this medical diagnosis? 1. Tarry stool 2. Orange stool 3. Green mucoid stool 4. Bright red-tinged stool

4. Bright red-tinged stool Rationale: Bright red-tinged stools are the cardinal sign of lower gastrointestinal bleeding. When bleeding occurs close to the anus, enzymes have not digested the blood, so the blood has not turned black.

A nurse is assessing a client's indwelling urinary catheter drainage at the end of the shift and notes the output is considerably less than the fluid intake. Which of the following actions should the nurse take first? 1. Irrigate the catheter. 2. Assess for peripheral edema. 3. Palpate for bladder distention. 4. Check the catheter for kinks.

4. Check the catheter for kinks. Rationale: The nurse should identify that output that is considerably less than intake is a sign that the catheter is blocked. Therefore, the first action the nurse should take is to check the tubing for kinks and ensure the client's urine flow is not obstructed. Option 1: If the catheter is blocked, the provider might have to prescribe catheter irrigation. However, this is not the first action the nurse should take. Option 2: The nurse should assess the extremities for peripheral edema. However, this is not the first action the nurse should take. Option 3: The nurse should palpate the bladder for distention. However, this is not the first action the nurse should take.

Which information about a client is communicated when a nurse documents that the client to include in the diet? 1. Beer 2. Coffee 3. Orange juice 4. Cranberry juice

4. Cranberry juice Rationale: Cranberries have no constituents that irritate the bladder. In addition, they produce a more acidic environment that is less conducive to the growth of microorganisms and prevents bacteria from adhering to the mucous membranes of the urinary tract, thus promoting bacterial excretion.

Which is an effective nursing intervention to prevent urinary tract infections? 1. Teach female clients to wipe from back to front after urinating 2. Advise clients to report during on urination to health-care providers 3. Instruct clients to use bath powder to absorb perineal perspiration 4. Encourage clients to drink several quarts of fluid daily

4. Encourage clients to drink several quarts of fluid daily Rationale: Drinking a minimum of 2,000 mL of fluid a day produces adequately dilute urine, washes out solutes, and flushes microorganisms from the distal urethra and urinary meatus.

A nurse is assessing a client who has a distended abdomen resulting from flatulence. The client has a prescription for a regular diet and an activity prescription for "out of bed." Which can the nurse do to promote passage of the intestinal gas? 1. Instruct the client to increase the amount of fluid intake 2. Suggest that the client avoid cruciferous foods 3. Obtain a prescription for a laxative 4. Encourage the client to ambulate

4. Encourage the client to ambulate Rationale: Ambulation increases metabolic activity, which increases intestinal peristalsis. Increased intestinal peristalsis moves intestinal gas toward the anus, where is can be expelled.

A nurse is teaching a client with a cardiac condition to avoid the Valsalva maneuver. Which should the nurse teach the client to do? 1. Eat rice several times a week 2. Take a cathartic on a regular basis 3. Attempt to have a bowel movement every day 4. Exhale while contracting the abdominal muscles

4. Exhale while contracting the abdominal muscles Rationale: Exhaling requires the glottis to be open, which prevents the Valsalva maneuver. the Valsalva maneuver is bearing down while holding the breath by closing the glottis, which increases intrathoracic pressure. The Valsalva maneuver briefly interferes with blood flow to the heart. When the glottis opens during exhalation, the pressure is released and a surge of blood flows to the heart, which may precipitate a dysrhythmia in a person with a cardiac condition.

A primary health-care provider discusses the need for a cystoscopy with a client. Which is the most important for the nurse to do when caring for this client before the cystoscopy? 1. Monitor the client's I&O 2. Assess the client's urine routinely 3. Encourage the client to increase the intake of oral fluid 4. Have the client sign an informed consent form before the procedure

4. Have the client sign an informed consent form before the procedure Rationale: During cystoscopy, a fiberoptic instrument is inserted through the urethra and into the bladder. It Is an invasive procedure that requires the client's written permission. Th primary health-care provider's discussion with the client includes the purpose of the procedure, its risks and benefits, and alternatives.

A client returns from the surgical unit after a transurethral resection of the prostate gland. The nurse reviews the primary health-care provider's prescriptions, obtains the client's vital signs, and performs a focused client assessment. Which is the best intervention by the nurse? 1. Discontinue the continuous compression devices to the lower extremities 2. Notify the surgeon of the status of the client's urinary drainage 3. Obtain the client's temperature using a rectal thermometer 4. Increase the flow rate of the continuous bladder irrigation

4. Increase the flow rate of the continuous bladder irrigation Rationale: The surgeons's prescriptions indicate that the continuous bladder irrigation should be maintained at a flow rate that keeps the urinary drainage oink; this also implies the absence of clots.

A nurse is preparing an adult client for an enema. the nurse should assist the client into which of the following positions? 1. Prone 2. Dorsal recumbent 3. Right lateral with both knees at chest 4. Left lateral with the right leg flexed

4. Left lateral with the right leg flexed Rationale: This position makes it easier for the enema solution to flow by gravity into the sigmoid and descending colon. The flexed leg promotes exposure of the anus for insertion of the rectal tube. Option 1: The prone position does not allow adequate visualization of the anus for safely inserting the rectal tube. Option 2: This position is used for infants and small children during enema administration, but it is not optimal for adults. Option 3: This position is difficult for clients to maintain, and it is unnecessarily extreme for enema administration.

A client is scheduled for a colonoscopy. the nurse will provide information to the client about which type of enema? 1. Oil retention 2. Return flow 3. High, large volume 4. Low, small volume

4. Low, small volume Rationale: Small-volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool (option 1). Return flow enemas help expel flatus (option 2). Because of the risk of loss of fluid and electrolytes, high, large-volume enemas are seldom used (option 3).

A primary health-care provider prescribes a return-flow enema for an adult client with flatulence. When preparing to administer this enema, the nurse compares the steps of a return-flow enema with those for cleansing enemas? 1. Lubricate the last 2 inches of the rectal tube. 2. Insert the rectal tube about 4 inches into the anus. 3. Raise the solution container about 12 inches above the anus. 4. Lower the solution container after instilling about 150 mL of solution.

4. Lower the solution container after instilling about 150 mL of solution. Rationale: Lowering the container of solution creates a siphon effect that pulls the instilled fluid back out through the rectal tube into the solution container. The return flow promotes the evacuation of gas from the intestines. This technique is used only with a return-flow enema. When performing a cleansing enema, the tubing is removed after all the solution is instilled.

Which should the nurse do when administering a small-volume hypertonic enema to an adult? 1. Insert the rectal tube 1 to 1.5 inches into the anal canal 2. Position the enema bottle 12 inches above the level of the client's anus 3. Direct the rectal tube toward the vertebrae as it is inserted into the rectum 4. Maintain the compression of the enema container until after withdrawing the tube

4. Maintain the compression of the enema container until after withdrawing the tube Rationale: Maintaining compression of the enema container until after withdrawing the tube prevents suctioning back of the fluid that has just been instilled. Releasing compression on the bottle causes a vacuum at the tip of the nozzle that can injure mucous membranes.

A nurse is evaluating a client's understanding of intermittent self-catheterization. Which of the following statements indicates a need for further teaching? Intermittent self-catheterization: 1. Reduces the incidence of urinary tract infections 2. Enables the client to retain independence and gain control of the bladder 3. Allows normal sexual relations without incontinence 4. Protects the lower urinary tract from reflux

4. Protects the lower urinary tract from reflux Rationale: Intermittent self-catheterization protects the upper urinary tract from reflux, reduces the incidence of urinary tract infection, enables the client to retain independence and gain control of the bladder, and allows normal sexual relations without incontinence.

A nurse must obtain a urine specimen from a client. Which nursing intervention is the greatest help to most people who need to void for a urine test? 1. Exerting manual pressure on the abdomen 2. Encouraging a backward rocking motion 3. Running water in the sink 4. Providing for privacy

4. Providing for privacy Rationale: Tending to bodily functions is a personal, private activity in the North American culture. Providing privacy supports client dignity and generally promotes voiding.

A nurse is assessing the urinary status of a client. Which sign indicates that additional nursing assessment are necessary? 1. Aromatic color 2. Pale yellow urine 3. Output of 50 mL hourly 4. Specific gravity of 1.035

4. Specific gravity of 1.035 Rationale: Specific gravity is the measure of the concentration of dissolved solids in the urine. The expected range is 1.010 to 1.025. A specific gravity of 1.035 indicates concentrated urine.

The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? 1. The bladder distends and its capacity increases 2. Older adults ignore the need to void 3. Urine becomes more concentrated 4. The amount of urine retained after voiding increases

4. The amount of urine retained after voiding increases Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3).

During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which specific type of urinary incontinence is the most appropriate for the nursing diagnosis? 1. Stress 2. Reflex 3. Functional 4. Urge

4. Urge Rationale: The key phrase is "the urge to void." Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function.

A client tells the nurse, "I have to urinate as soon as I get the urge to go." For which contributing factor to urinary urgency should the nurse implement a focused assessment? 1. Anesthesia 2. Dehydration 3. Full bladder 4. Urinary tract infection

4. Urinary tract infection Rationale: Feeling the need to void immediately (urgency) occurs most often when the urinary bladder is irritated. In the adult, the usual bladder capacity 400 to 600 mL of urine, although the desire to urinate can be sensed when it contains as little as 150 to 200 mL. As the volume increases, the bladder wall stretches, sending sensory messages to the sacral spinal cord, and parasympathetic impulses stimulate the detrusor muscle to contract rhythmically. Bladder contractions precipitate nerve impulses that travel up the spinal cord to the pons and cerebral cortex, where the person experiences a conscious need to void.

A nurse must obtain a clean-catch urine specimen from one client and a urine specimen via straight cauterization from another. Which intervention is not performed for both when obtaining these specimens? 1. Cleanse around the urinary meatus with antiseptic swabs 2. Send the specimen to the laboratory immediately 3. Use a sterile cup to collect the specimen 4. Wear sterile gloves during the procedure

4. Wear sterile gloves during the procedure Rationale: Sterile gloves must be worn when obtaining a urine specimen via a catheter. The nurse's hands touch the client and catheter tubing, which must remain sterile. Clean, rather than sterile, gloves are worn with obtaining a clean-catch urine specimen. Urine flowing out of the client is collected midstream into a sterile specimen cup.

A nurse is caring for a female client on bedrest who has a urinary retention catheter. Which should the nurse do? Select all that apply. 1. Position the tubing through the side rail of the bed 2. Ensure the tubing is positioned under the leg 3. Label the tubing with the date of insertion 4. Irrigate the tubing to ensure its patency 5. Secure the tubing to the client's leg

5 Rationale: Securing the tubing to the client's leg prevents tension on the urinary meatus.

A primary health-care provider prescribes a bladder ultrasound scan to be performed after a client cords to determine the amount of residual urine. The nurse explains the test to a client. Place the following steps in the order that they should be performed by the nurse. 1. Clean the client's abdomen to remove the gel and clean the scan head with isopropyl alcohol 2. Put 5 mL of conducting gel on the client's symphysis pubis and place the scan head on the gel 3. Aim the scan head toward the client's coccyx and press the scan head button 4. Drape the client, exposing only the lower abdomen and suprapubic area 5. Obtain the bladder volume and repeat the measurement several times 6. Place the client in the supine position

6, 4, 2, 3, 5, 1 Rationale: 6: The supine position permits access to the client's lower abdomen and suprapubic area. 4: Draping the client and exposing just the lower abdomen and suprapubic area provide for client privacy. 2: The use of conducting gel or an ultrasound gel pad improves transmission of the ultrasound image. 3: The scan head should be placed approximately 1.5 inches (4 cm) above the pubic bone midline below the umbilicus (symphysis pubis ) while aiming the scan head toward the coccyx. This permits visualization of the urinary bladder. In women, the bladder lies in front of and below the uterus. In men, the bladder can be partly obstructed by the pubic bone, and the scan head may require a slightly oblique angle to visualize the bladder. 5: Several measurements should be obtained to ensure accuracy of the results. 1: Removing the gel and washing the client's abdomen promote hygiene and comfort. Cleaning the scan head removes the gel on the end of the probe.