1430 Elimination

When administering a cleansing enema, which techniques should the nurse use? (Select all that apply.) a. Assist the patient to a left side-lying (Sims) position. b. Add room-temperature solution to enema bag. c. Lubricate 2 to 4 cm (1 to 2 inches) of tip of rectal tube with lubricating jelly. d. Raise container, release clamps, and allow solution to fill tubing before administration. e. Clamp tubing after solution is instilled

a. Assist the patient to a left side-lying (Sims) position. d. Raise container, release clamps, and allow solution to fill tubing before administration. e. Clamp tubing after solution is instilled The patient should be assisted to the left side-lying (Sims) position. The container release clamps must be released and the solution allowed to flow to fill the tubing. After the solution is instilled, the tubing should be clamped. Solution should be warmed to slightly warmer than body temperature (or 100° to 105° F) to prevent cramping. The tip of the rectal tube should be lubricated 6 to 8 cm (3 to 4 inches).

A patient with an indwelling catheter reports a need to void. What is the priority intervention for the nurse to perform? a. Check to see if the catheter is patent. b. Reassure the patient that it is not possible to void while catheterized. c. Catheterize the patient again with a larger gauge catheter. d. Notify the primary care provider.

a. Check to see if the catheter is patent. Checking the position and patency of the catheter first will determine whether the problem is mechanical or physiologic. At times, the end of the catheter may become lodged up against the side of the bladder, preventing the flow of urine into the tubing. Telling the patient that is impossible to void while catheterized is erroneous. Catheterizing the patient with a larger-gauge catheter is unnecessary at this point, as is contacting the primary care provider.

The teaching plan for a patient with diarrhea should include which intervention? a. Drinking at least eight glasses of fluid each day b. Eating foods low in sodium and potassium c. Limiting the amount of soluble fiber in the diet d. Eliminating whole-wheat and whole-grain breads and cereal

a. Drinking at least eight glasses of fluid each day Diarrhea is associated with high risk for dehydration, so the patient should increase the fluid intake. The patient may need increased sodium and potassium intake owing to loss of these electrolytes in the frequent stools. Fiber will add bulk and help form the stools so should be increased. Whole-grain products contain fiber.

1. Which organism is responsible for the majority of urinary tract infections in female patients? a. Escherichia coli b. Neisseria gonorrhoeae c. Candida albicans d. Haemophilus influenza

a. Escherichia coli Urinary tract infections (UTIs) are the result of bacteria in the urine. Infection occurs when bacteria from the digestive tract, usually E. coli, invade the urethra and multiply. N. gonorrhoeae causes gonorrhea. C. albicans causes yeast infections. H. influenza causes influenza.

Nursing interventions for the patient who suffers from stress incontinence include: a. Kegel exercises. b. surgical interventions. c. bowel retraining. d. intermittent catheterization.

a. Kegel exercises. Kegel exercises also are known as pelvic floor exercises. They improve muscle tone in the pelvic floor, which helps to prevent stress incontinence.

The nursing instructor is teaching information about constipation in the elderly. Which statement from the student indicates a need for further instruction on this topic? a. Patients receiving tube feedings often experience constipation. b. Poor fluid intake and inability to eat a high-fiber diet often cause constipation. c. Patients with impaired mobility may experience constipation. d. Medications commonly taken by elders often contribute to constipation.

a. Patients receiving tube feedings often experience constipation. Patients on tube feedings often experience diarrhea, not constipation.

Prior to discharge, the nurse teaches the patient the proper techniques for applying an ostomy pouch. When evaluating the teaching, the nurse observes the patient apply a new ostomy pouch without cleansing the skin underneath. What actions would the nurse implement following this patient's return demonstration? (Select all that apply.) a. Repeat the demonstration to show the patient how to clean the ostomy site. b. Document that the patient performed the initial return demonstration accurately and safely. c. Offer positive reinforcement regarding the need to cleanse the site to prevent skin breakdown below the appliance. d. Discharge the patient with written instructions and illustrations that demonstrate the correct procedure. e. Notify the health care provider that a repeat demonstration of the ostomy appliance procedure is needed.

a. Repeat the demonstration to show the patient how to clean the ostomy site. c. Offer positive reinforcement regarding the need to cleanse the site to prevent skin breakdown below the appliance. d. Discharge the patient with written instructions and illustrations that demonstrate the correct procedure. The initial return demonstration was not performed accurately, and since it is the nurse's responsibility to complete the needed teaching, the health care provider does not need to be notified. Discomfort and damage to the skin can result from not washing the site; therefore, the nurse would repeat the demonstration, emphasizing the importance of cleansing. Positive reinforcement and the provision of written instructions are valuable teaching strategies.

To prevent constipation in an inactive patient, which early interventions should the nurse implement? (Select all that apply.) a. Stool softener administration b. Enema administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake

a. Stool softener administration c. Increasing the fiber in the diet d. Increasing physical activity e. Increasing fluid intake Administering stool softeners, increasing the fiber and fluids in the diet, and increasing physical activity are all early interventions to prevent constipation. Although used to treat constipation, an enema would not be an early intervention for prevention.

When emptying a patient's catheter drainage bag, the nurse notes that the urine appears to be discolored. The nurse understands that what factors may change the color of urine? (Select all that apply.) a. Taking the urinary tract analgesic phenazopyridine b. A diet that includes a large number of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease e. Increased carbohydrate intake

a. Taking the urinary tract analgesic phenazopyridine b. A diet that includes a large number of beets or blackberries c. An enlarged prostate or kidney stones d. High concentrations of bilirubin secondary to liver disease Urine may appear orange when a patient is taking phenazopyridine. Urine can appear red or pink with a diet including beets or blackberries and if blood is present in the urine, which may be secondary to an enlarged prostate or kidney stones. Urine often has a brownish appearance when liver disease such as hepatitis or cirrhosis is present. Carbohydrate intake does not typically cause urine to be discolored.

A patient with a history of diarrhea is seen in the clinic. Which nursing intervention is most essential to include in this patient's plan of care? a. Weighing the patient daily b. Encouraging a diet high in fiber c. Decreasing the patient's fluid intake d. Instructing the patient to increase protein in the diet

a. Weighing the patient daily The patient with diarrhea is susceptible to dehydration. Checking the patient's weight daily will monitor fluid status. Fiber will help firm up the stools but is not the priority. The patient should increase fluid intake. Increasing protein will not help the diarrhea.

The nurse is inserting an indwelling catheter into a male patient. While initially passing the catheter through the urethra, resistance is met. What action would the nurse take next? a. Withdraw the catheter and obtain a coude catheter. b. Straighten the penis and attempt to progress the catheter again. c. Remove the catheter and insert one with a smaller lumen. d. Inflate the balloon and wait for urine passage

a. Withdraw the catheter and obtain a coude catheter. Coudé catheters are a special type of double-lumen, indwelling catheters that are slightly stiff and bent at the end, allowing the catheter to pass more easily through a partially constricted urethra. They are used mostly in men experiencing prostate enlargement or BPH. The nurse would not continue trying to advance the catheter, try one with a smaller lumen, or inflate the balloon before the catheter was properly inserted.

Average urine pH is: a. 4. b. 6. c. 7. d. 9.

b. 6. Urine normally is slightly acidic, with an average pH of 6.

Which nursing instruction is correct when a urine specimen is collected for culture and sensitivity testing from a patient without a urinary catheter? a. Tell the patient to void and pour the urine into a labeled specimen container. b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container. c. Instruct the patient to discard the first void and collect the next void for the specimen. d. Have the patient keep all voided urine for 24 hours in a chilled, opaque collection container.

b. Ask the patient to void first into the toilet, stop midstream, and finish voiding into the sterile specimen container. Urine specimens for culture and sensitivity testing must be collected in sterile containers using the clean-catch, midstream method whenever possible. All voided urine specimens should be collected directly into the specimen container, not transferred to another, potentially contaminated receptacle. Discarding the entire first void and saving urine in a chilled, opaque container are both procedures for conducting a 24-hour urine collection.

The nurse is assessing a patient with an indwelling catheter and finds that the catheter is not draining and the patient's bladder is distended. What action should the nurse take next? a. Notify the primary care provider. b. Assess the tubing for kinks and ensure downward flow. c. Change the catheter as soon as possible. d. Aspirate the stagnant urine in the catheter for culture.

b. Assess the tubing for kinks and ensure downward flow. The next action by the nurse should be to check the patency of the catheter tubing. At this point there is no need to aspirate any urine or call the primary care provider. The catheter should not be changed unless absolutely necessary, owing to the possibility of causing an infection.

A 40-year-old patient complains of 4 days of frequent loose stools with abdominal cramping. What is the priority nursing diagnosis for this patient? a. Impaired Skin Integrity b. Fluid Imbalance c. Acute Pain d. Self-Care Deficit (i.e., toileting)

b. Fluid Imbalance Diarrhea can cause dehydration with loss of fluids and electrolytes. There is no statement of problems with the skin, although this patient may be at risk for skin breakdown if the diarrhea continues. In addition, no self-care deficit is stated for this patient. Although the patient has experienced cramping and the pain needs to be addressed, the main consideration would be correction of any fluid and electrolyte problems, followed by determination of the cause of the diarrhea.

A patient is scheduled for an intravenous pyelogram (IVP). Which piece of data would be most important to know before the procedure is carried out? a. Urinalysis negative for sugar and acetone b. History of allergies c. History of a recent thyroid scan d. Frequency of urination

b. History of allergies Contraindications for intravenous pyelogram (IVP) include an allergy to iodine, which is similar to the contrast material injected during the IVP. Knowing this information would be critical to providing safe patient care. Frequency of urination may be an indication to perform an IVP; however, this is not critical to know before performing an IVP. The results of a urinalysis and history of a recent thyroid scan would not affect a scheduled IVP.

The nurse is placing an indwelling catheter in a female patient. The nurse accidentally inserts the catheter into the vagina. What is the next action for the nurse to implement? a. Collect a urine specimen and notify the primary care provider (PCP). b. Leave the catheter in place and insert a new catheter into the urethra. c. Remove the catheter from the vagina and place it into the urethra. d. Ask another nurse to attempt the catheterization of the patient.

b. Leave the catheter in place and insert a new catheter into the urethra. By leaving the first catheter in place in the vagina, the nurse can more accurately identify the urethra for insertion of the new catheter. This prevents misplacing the new catheter into the vagina during the second catheterization attempt. The catheter that was placed in the vagina is no longer sterile, so it should not be reused and should be discarded after the new catheter is properly placed into the bladder. It is impossible to get a urine sample from the catheter placed in the vagina. Only after having trouble with proper placement of the new catheter may the nurse wish to ask for assistance from another nurse.

An indwelling catheter is ordered for a postoperative patient who is unable to void. What is the primary concern of the nurse performing the procedure? a. Teaching deep-breathing techniques b. Maintaining strict aseptic technique c. Medicating the patient for pain before the procedure d. Positioning the patient for comfort during the procedure

b. Maintaining strict aseptic technique It is most important to maintain strict aseptic technique while inserting an indwelling catheter, to try to prevent a urinary tract infection. It is not necessary to medicate patients before urinary catheterization. Although comfortable positioning and deep breathing may help relax the patient, this is not the primary concern.

A patient is being discharged from the hospital with a new ileostomy. The patient expresses concern about caring for the ostomy. Before hospital discharge, it is most important for the nurse to coordinate with which member of the health care team? a. Home care nurse b. Wound ostomy continence nurse c. Registered dietitian d. Primary care provider

b. Wound ostomy continence nurse The wound ostomy continence nurse (WOCN) is the most important person to contact to schedule teaching sessions and follow-up care. This nurse specialist is certified in the treatment of patients who have a bowel or bladder diversion. Although team input is important, the contribution of the WOCN is paramount to help the patient achieve competence and comfort with self-care before discharge.

A patient is scheduled for a colonoscopy. After preprocedure teaching by the nurse, the patient demonstrates understanding when he makes which statement? a. "I can have coffee the morning of the procedure." b. "I should drink a red sports drink the day before to stay hydrated." c. "I should drink clear liquids for 2 days before the procedure." d. "I will be able to drive home immediately after the procedure."

c. "I should drink clear liquids for 2 days before the procedure." The patient will be on a clear liquid diet for 1 to 3 days before the procedure. The patient should not eat or drink anything immediately before the procedure. Drinks with red or purple dye are contraindicated because they could interfere with the examination findings. Patients are given medications during the procedure that alter the sensorium and therefore need to have someone else drive them home.

What would be included in teaching for a patient who will be discharged with a prescription for a laxative? a. Calling the health care provider if nausea, vomiting, or abdominal pain occurs b. Continuing use of laxatives to encourage bowel evacuation c. Adding regular exercise, sufficient fluids, and regular defecation habits to his/her routine d. Knowing the difference between laxatives and cathartics

c. Adding regular exercise, sufficient fluids, and regular defecation habits to his/her routine The patient who is discharged on laxatives should still be instructed on the nonpharmacologic methods to decrease constipation and promote normal bowel patterns. Laxatives are contraindicated in patients with nausea, vomiting, or undiagnosed abdominal pain. Ongoing use of laxatives is associated with harmful side effects, such as an increase in constipation and impaction, predisposition to colorectal cancer, dependency, and electrolyte imbalance and should not be encouraged. Knowing the difference between laxatives and cathartics will not help the patient in this case.

What self-care measure is most important for the nurse to include in the teaching plan for a patient who will be discharged with a urostomy? a. Change the appliance before going to bed. b. Cut the wafer 1 inch larger than the stoma. c. Cleanse the peristomal skin with mild soap and water. d. Use firm pressure to attach the wafer to the skin.

c. Cleanse the peristomal skin with mild soap and water. The peristomal area should be washed by the patient using warm water and mild soap as needed and routinely at bath time. The collection device typically has a face plate to ensure a good fit and prevent leakage of urine. These appliances are changed less frequently than before bed each night, and neither a widely cut wafer nor firm pressure is needed for their application.

Which discharge instruction does the nurse provide to the patient following a colonoscopy? a. Some discomfort and bleeding are normal postprocedure. b. Return to the emergency room if you experience abdominal cramping. c. Do not drive or operate heavy machinery for 12 hours postprocedure. d. Return to your normal bowel pattern immediately postprocedure.

c. Do not drive or operate heavy machinery for 12 hours postprocedure. Since sedation is given for the procedure, the patient should not drive or operate heavy machinery. Cramping and bloating can be seen in the first hour afterward. The patient's normal pattern for bowel elimination will not return immediately.

Which nursing intervention is included for a patient experiencing diarrhea? a. Limiting fluid intake to 1000 mL/day b. Administering a cathartic suppository c. Increasing fiber in the diet d. Limiting exercise

c. Increasing fiber in the diet Fiber is encouraged in patients with diarrhea to add bulk to the stools. Fluid intake and exercise should be encouraged. Cathartics would not be used because they are strong laxatives used to soften the stool and evacuate the bowels.

To best determine the patient's competency in changing an ostomy appliance, what does the nurse ask the patient to do? a. Verbalize the procedure. b. Identify the supplies needed. c. Perform the procedure. d. List the steps in the procedure.

c. Perform the procedure. Repeat performance is the best way to ensure competency. The other actions demonstrate knowledge in limited specifics of the procedure.

A female patient has had frequent urinary tract infections. Which statement by the patient indicates that the nurse's teaching on prevention has been effective? a. "I will limit my fluid intake to 40 ounces per day." b. "I will use only organic bath bombs when bathing." c. "I will wait to wear my tight jeans until after my urine is clear." d. "I will wipe from the front to back after voiding."

d. "I will wipe from the front to back after voiding." Wiping the female perineal area from front to back after voiding is crucial in the prevention of microorganisms, which lead to infection, being transferred from the rectum or vagina to the urethral meatus. Limiting fluid intake, using any type of bath bombs, and wearing tight-fitting clothing all may contribute to the promotion of urinary tract infections rather than their prevention.

A patient is scheduled for an upper GI series. Which information is most important for the nurse to obtain before the procedure? a. Allergy to shellfish b. Last bowel movement c. Time the enema was administered d. Any difficulty swallowing

d. Any difficulty swallowing The patient will need to drink barium for this x-ray; therefore, swallowing ability should be assessed prior to the start of the procedure. The test does not use contrast dye, so the allergy to shellfish is not related. Time of the last bowel movement and enema administration is also not related since the test is not of the lower GI tract.

While performing an abdominal assessment on an unconscious patient, the nurse notes presence of an ostomy. The fecal output is liquid in consistency, with a pungent odor, from the stoma that is located in the upper right quadrant of the abdomen. What type of ostomy does the patient have? a. Descending colostomy b. Ureterostomy c. Ileostomy d. Ascending colostomy

d. Ascending colostomy An ascending colostomy meets the description of fecal output of liquid consistency and with a pungent odor, as well as location of the stoma in the upper right quadrant of the abdomen. Descending colostomies produce increasingly formed stool. An ileostomy will produce liquid stool but with less odor because enzyme activity is not present. Ureterostomies drain urine, not stool.

The nurse is assigned the care of a patient for whom a cleansing enema has been ordered. What information is most important for the nurse to know before administration of the enema? a. The proper way to position the patient b. Signs and symptoms of intolerance to the procedure c. Vital signs before the procedure d. History of surgery of the anus or rectum

d. History of surgery of the anus or rectum The most important item in preadministration assessment data is a history of surgery to the anus or rectum, which may contraindicate enema administration. The nurse needs to know the proper patient position for an enema and must observe for signs of intolerance to the procedure, but these are done during the procedure. Vital signs are not routinely obtained before an enema.

Which nursing intervention would be the highest priority when caring for a patient complaining of voiding small amounts of urine in relation to his fluid intake? a. Placing a disposable waterproof pad on the patient's bed before he goes to sleep. b. Documenting in the patient's electronic health record that he is complaining of anuria. c. Notifying the patient's primary care provider (PCP) of the need for intermittent catherization. d. Palpating the patient's bladder for distention before scanning for possible retention.

d. Palpating the patient's bladder for distention before scanning for possible retention. The highest priority nursing intervention for a patient experiencing oliguria (reduced urine volume) is to check the patient for bladder distention and retention. Placing a waterproof pad on the patient's bed at bedtime would be more appropriate if the patient was incontinent or experiencing nocturia (excessive urination at night). Documentation of anuria (excretion of 50-100 mL or less of urine each day) would be erroneous since the patient is complaining of repeatedly passing small amounts of urine. Notifying the primary care provider may be necessary, but only after the patient is assessed for distention and retention that is not resolved by other less invasive methods of relief.

The nurse knows that the teaching for a patient who was recently diagnosed with constipation has been effective if the patient's meal request specifies which food choice? a. Hot dog on a bun b. Grilled chicken c. Tuna sandwich on white bread d. Spinach salad with dressing

d. Spinach salad with dressing Green leafy vegetables are high in fiber. None of the other options are high in fiber but could be modified by using or adding whole-grain products.

A patient with a history of kidney stones is experiencing difficulty urinating and laboratory findings indicate the patient is in acute renal failure. What is the probable cause of this condition? a. Hypovolemia b. Cardiogenic shock c. Nephrotoxic substances d. Urethral obstruction

d. Urethral obstruction Inadequate flow or complete obstruction by anything (such as stones or tumors) that blocks both ureters and the bladder, or obstructs the urethra, resulting in acute or chronic renal failure. With a history of kidney stones, it is most probably that one is moving down the urinary tract and got lodged, leading the patient to have difficulty urinating.

The patient is ordered an ultrasound of the kidneys. The nurse knows that prior to the test the patient will: a. be required to have a bowel cleansing enema. b. be checked for any allergies to shellfish. c. be required to drink a large amount of fluids before the test. d. have no pretest requirements.

d. have no pretest requirements. An ultrasound scan may be performed to assess the size, shape, and location of the kidneys. Ultrasound studies may be safely conducted in patients who have allergies to contrast media, because no radiation or contrast dyes are used. No patient preparation such as fasting or sedation is required.

Select the most appropriate goal for a patient experiencing diarrhea related to antibiotic use: a. the patient will return to previous elimination pattern. b. the patient will increase intake of grains, rice, and cereals. c. the patient will discontinue antibiotic use. d. the patient will increase fluid intake.

d. the patient will increase fluid intake. The highest priority goal is for the patient to increase fluid intake since diarrhea can lead to dehydration.

Nurse Beth should advance the catheter ________ to _______ inches or until urine flows out of it.

7 to 9 Rationale: In an adult male the catheter should be advanced 7 to 9 inches (17-22.5 cm) or until urine flows out of it.

To determine which bowel elimination methods work best for Mrs. Butler, the nurse asks which of the following pertinent assessment questions? (Select all that apply.) A. "What is your regular bowel routine?" B. "Do you use laxatives, enemas, or stool softeners at home?" C. "What is your typical daily diet?" D. "Do you take iron supplements at home?" E. "What time do you go to sleep each evening?"

A. "What is your regular bowel routine?" B. "Do you use laxatives, enemas, or stool softeners at home?" C. "What is your typical daily diet?" D. "Do you take iron supplements at home?" Rationale: Asking patients about their regular bowel routine, bowel medications used at home, diet, and use of supplements helps determine the best bowel plan for the patient.

The nurse notices that Mrs. Butler has been taking her as needed (prn) pain medication, hydrocodone 5 mg/acetaminophen 500 mg, every 4 hours as ordered. While the nurse is assessing Mrs. Butler's pain to determine if another dose of pain medication is needed, Mrs. Butler states that she hasn't had a bowel movement (BM) since her surgery 3 days ago. The nurse knows that Mrs. Butler's constipation is most likely caused by which of the following? A. Opioid use for pain management B. Mrs. Butler's age C. Too much fat in Mrs. Butler's diet D. The thyroidectomy procedure

A. Opioid use for pain management Rationale: Opioid medications contribute to constipation in surgical patients. The hydrocodone portion of Mrs. Butler's pain medication is an opioid analgesic. A stool softener and laxative are needed to prevent constipation after surgery.

Nurse Beth enters Mr. Kelter's room after lunch to perform straight catheterization. List in order the steps Beth takes to perform straight catheterization on Mr. Kelter. A. Lubricate the catheter. B. Clean penis with dominant hand. C. Apply sterile gloves. D. Advance catheter into penis. E. Apply fenestrated drape. F. Hold penis with nondominant hand. G. Ask patient to bear down. H. Coil catheter in dominant hand.

C. Apply sterile gloves. E. Apply fenestrated drape. A. Lubricate the catheter. F. Hold penis with nondominant hand. B. CleaH. Coil catheter in dominant hand.n penis with dominant hand. G. Ask patient to bear down. D. Advance catheter into penis. Rationale: The steps of straight catheterization are to position the patient, apply sterile gloves, apply the fenestrated drape, lubricate the catheter, hold the penis with the nondominant hand, clean the penis with the dominant hand, coil the catheter in the dominant hand, ask the patient to bear down, and advance the catheter into the penis.

As Nurse Beth inserts the catheter into Mr. Kelter's penis, she feels resistance. She should use more force to guide the catheter through his urethra. A. True B. False

False Rationale: When resistance is felt while inserting a catheter, withdraw the catheter and do not force it. If there is resistance to the catheter insertion, have the patient take slow, deep breaths while slowly inserting the catheter. When urine appears, advance the catheter another 2.5 to 5 cm (1 to 2 inches).

The nurse knows that it is important to immediately start Mrs. Butler on a bowel medication regimen to prevent fecal impaction. Unresolved fecal impaction can result in _______________ ______________.

Intestinal obstruction Rationale: Unresolved severe fecal impaction can result in intestinal obstruction that requires surgical intervention.