Elimination

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema? Click on the image to indicate your answer.

Answer is 2 which is a person laying on their left side in sim's position

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction?

1. "The enema will be given while I am sitting on the toilet." 2. "I should try and hold the fluid as long as possible after it is instilled." 3. "I know that there will be some cramping after the enema administration." 4. "I should tell the nurse if cramping occurs during the instillation of the fluid." Answer-1

The nurse is caring for a client with chronic kidney disease. The nurse knows that besides maintaining urinary elimination, the kidneys also are involved in what body processes? Select all that apply.

1. Help regulate blood pressure. 2. Encourage immunosuppression. 3. Stimulate liver to secrete enzymes. 4. Assist to regulate acid-base balance. 5. Convert vitamin D to an active form. 6. Produce erythropoietin for red blood cell synthesis. Answer-1,4,5,6

A client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time?

1. High-fiber diet 2. Full liquid diet 3. Low-fiber diet 4. Low-sodium diet Answer-1

The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next?

1. Immediately twist the catheter, and then slowly inflate the balloon. 2. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. 3. Insert the catheter until resistance is met, and then inflate the balloon. 4. Withdraw the catheter approximately 1 inch (2.5 cm), and then inflate the balloon. Answer-2

Before enema administration, the nurse positions the client in the left lateral postion. What is the rational for using this position?

1. It is more comfortable. 2. It facilitates the passage of stool. 3. It prevents a vasovagal response from occurring. 4. It facilitates instillation of the enema solution into the colon. Answer-4

The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position?

1. Left-sided lateral Sims' position 2. Right-sided lateral Sims' position 3. Left side-lying, with the head of the bed elevated 45 degrees 4. Right side-lying, with the head of the bed elevated 45 degrees Answer-1

The nurse is caring for a 1-day postoperative client who is complaining of urinary retention. What are some of the initial assessment techniques or interventions the nurse should employ? Select all that apply.

1. Palpation 2. Inspection 3. Percussion 4. Auscultation 5. Bladder scanner 6. Insertion of Foley catheter Answer-1,2,3,5

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action?

1. Withdraw the catheter slightly and reinflate the balloon. 2. Remove the catheter, and reinsert a new one that is 1 size smaller. 3. Finish inflating the balloon; the discomfort is normal and temporary. 4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon. Answer-4