Elimination and Thermoregulation practice

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should plan to administer the client's PRN bethanechol when the client reports which of the following manifestations? a. Bladder spasms b. Severe pain. c. An inability to void d. Frequent episodes of painful urination

An inability to void Bethanechol is a cholinergic medication that stimulates the parasympathetic nervous system, thus improving the tone and motility of the smooth muscles of the urinary tract enough to initiate urination.

A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? a. Notify the provider. b. Check the tubing for kinks. c. Adjust the rate of the bladder irrigant. d. Irrigate the catheter.

Check the tubing for kinks. When providing client care, the nurse should first use the least restrictive intervention; therefore, the nurse should check the catheter tubing for kinks. The nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage from the catheter to prevent clotting, which could occlude the catheter lumen.

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? a. Nephrosclerosis b. Uremia c. Diverticulitis d. Cystitis

Cystitis A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). The nurse should expect which of the following findings? a.Urge incontinence b. Critically elevated prostate-specific antigen (PSA) level c. Difficulty starting the flow of urine d. Painful urination

Difficulty starting the flow of urine Hesitancy or difficulty starting the flow of urine is an expected finding of BPH.

A nurse on the labor and delivery unit is caring for a newborn immediately following birth. Which of the following actions by the nurse reduces evaporative heat loss by the newborn? a. Placing the newborn on a warm surface b. Preventing air drafts c. Drying the newborn's skin thoroughly d. Maintaining ambient room temperature at 24° C (75° F)

Drying the newborn's skin thoroughly Heat loss through evaporation occurs when moisture on the skin is converted to a vapor. This process is the most significant cause of heat loss in the first few days of life but is minimized by quickly and thoroughly drying the infant

A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take? a. Assist the client to the bathroom every 2 hr. b. Restrict oral fluid intake during waking hours. c. Encourage the client to hold her breath when feeling the urge to urinate. d. Provide adult diapers until bladder retraining is successful.

Encourage the client to hold her breath when feeling the urge to urinate. The nurse should encourage the client to take deep, slow breaths to help diminish the urge to urinate.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) a. Excessive laxative use b. Ignoring the urge to defecate c. Inadequate fluid intake d. Increased fiber in the diet e. Increased activity

Excessive laxative use is correct. Chronic use of laxatives causes the large intestine to lose muscle tone and become less responsive to stimulation by laxatives. Ignoring the urge to defecate is correct. Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause alterations in bowel habits, such as constipation. Inadequate fluid intake is correct. Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool.

A nurse is caring for a client who has benign prostatic hyperplasia (BPH). Which of the following medications should the nurse plan to administer? a. Danazol b. Finasteride c. Fluoxymesterone d. Methyltestosterone

Finasteride Finasteride, a 5-alpha-reductase inhibitor, is used in the treatment of BPH to prevent the conversion of testosterone and to decrease prostate size.

A nurse is caring for a client who is postoperative following a transurethral resection of the prostate. Which of the following complications is the priority for the nurse to monitor for? a. Hemorrhage b. Infection c. Urinary retention d. Pain

Hemorrhage Using the airway breathing circulation (ABC) approach to client care the nurse determines that the priority complication to monitor for is the client hemorrhaging; therefore, the nurse should monitor the client's urinary output for blood clots and bright red blood tinged urine following surgery.

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? a. Bear down hard when defecating. b. Drink four to five glasses of water daily. c. Increase dietary intake of raw vegetables. d. Limit activity.

Increase dietary intake of raw vegetables. The client should increase dietary intake of raw vegetables to help provide fiber in the diet, which will increase stool bulk and move the stool through the colon to prevent constipation.

A nurse is teaching a client who has constipation about a high-fiber diet. Which of the following foods should be included as sources of fiber? (Select all that apply.) a. Kidney beans b. Blackberries c. Refined cereals d. Whole wheat bread e. Lean turkey

Kidney beans should be included in the teaching as a source of fiber. Blackberries should be included in the teaching as a source of fiber. Whole wheat bread should be included in the teaching as a source of fiber.

A nurse is preparing to administer bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply.) a. Don sterile gloves. b. Lubricate index finger. c. Use a rectal applicator for insertion. d. Position client supine with knees bent. e. Insert suppository just beyond internal sphincter.

Lubricate index finger is correct. The rounded end of the suppository is lubricated with a sterile water-soluble lubricating jelly. Insert suppository just beyond internal sphincter is correct. The nurse should gently retract the buttocks with the nondominant hand. Insert the suppository gently through the anus, past the internal sphincter, and against the rectal wall. Following the administration of the medication, the nurse should apply gentle pressure to hold the buttocks together momentarily if needed to keep medication in place.

A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication? a. Output of burgundy colored urine b. Pulse rate of 88/min c. Oral temperature of 38.2° C (100.76° F) d. An urge to void despite having an indwelling urinary catheter

Output of burgundy colored urine Output of burgundy colored urine may indicate venous bleeding, a potential complication following a TURP. Should this occur, the nurse should inform the provider and anticipate an order for increased CBI rate or manual irrigation of the catheter.

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? a. Stress incontinence b. Urge incontinence c. Overflow incontinence d. Reflex incontinence

Overflow incontinence These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.

A nurse is planning care for a client who is 2 hr postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include? a. Restrict the client's oral fluid intake. b. Remind the client he might feel a constant urge to void. c. Monitor the client's urine output every 6 hr. d. Weigh the client every evening.

Remind the client he might feel a constant urge to void. The client who is receiving continuous bladder irrigation will experience a continuous urge to void because of pressure on the internal sphincter from the catheter balloon.

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) a. Report of feeling pressure b. Tenderness over the symphysis pubis c. Distended bladder d. Voiding 30 mL frequently e. Dysuria

Report of feeling pressure is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. Tenderness over the symphysis pubis is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis. Distended bladder is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder. Voiding 30 mL frequently is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine.

A nurse is administering a cold therapy application to a client. Which of the following manifestations should the nurse identify as an indication for discontinuing the application due to a systemic response? a. Hypotension b. Numbness c. Shivering d. Reduced blood viscosity

Shivering Shivering is a systemic response to cold therapy as the body attempts to promote heat production.

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications? a. Dehydration b. Seizures c. Burns d. Shivering

Shivering The hypothermia blanket, if used improperly (at inappropriately low temperatures, or without skin protection), can cause the client to cool too fast, leading to shivering. To prevent heat loss from the skin, the body becomes peripherally vasoconstricted in an attempt to reduce heat loss. The body will also try to increase heat production by shivering, which can increase the metabolic rate by two to five times and in doing so greatly raise oxygen consumption.

A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? a. Remind the client to tell the nurse when he has to urinate. b. Use adult diapers to prevent frequent clothing changes. c. Take the client to the bathroom every 2 hr. d. Request a prescription for an indwelling urinary catheter.

Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.

A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? a. Perform catheterization when you recognize the urge to void. b. Hold the penis at a 30° to 45° angle when inserting the catheter. c. Inflate the balloon when the urine flow stops. d. Use soap and water to wash the catheter after each use.

Use soap and water to wash the catheter after each use. The client should wash the catheter using soap and water and store it in a clean container after each use.

A nurse is caring for a client who is 1 day postoperative following a transurethral resection of the prostate (TURP) and has a continuous bladder irrigation in place. Which of the following actions should the nurse take? (Select all that apply.) a. Add the amount of bladder irrigation to the total output. b. Use sterile technique when preparing the irrigation solution. c. Ensure the drainage tubing is patent and without obstruction. d. Contact the surgeon if the client reports a continual need to void. e. Notify the surgeon if the urine is bright red in appearance or has large clots.

Use sterile technique when preparing the irrigation solution is correct. Using sterile technique decreases the risk of contamination with micro-organisms and reduces the possibility of infection. Many clients who undergo a TURP are older adults who may have other chronic diseases that increase their susceptibility to infection. These clients should also be observed closely for manifestations of infection, such as fever and elevated WBC. Ensure the drainage tubing is patent and without obstruction or kinks is correct. For continuous drainage, the nurse should be sure that the clamp on the drainage tubing is open and check the volume of fluid in the drainage bag. It prevents accumulation of solution in the bladder, which can cause bladder distention and possible injury. Notify the surgeon if the urine is bright red in appearance or has large clots is correct. It is normal to see a few small blood clots and pink tinged drainage, but urine that is bright red, ketchup-like, or has large clots is an indication of bleeding and should be reported to the surgeon.

A nurse is implementing a bowel training program for a client. For the program to be effective, the nurse should take the client to the toilet at which of the following times? a. When the client has the urge to defecate b. Every 2 hr while the client is awake c. Immediately before the client has a meal d. After the client feels abdominal cramping

When the client has the urge to defecate When on a bowel training program, the nurse should take the client to the toilet when the client recognizes the urge to defecate. A bowel training program focuses on identifying times in the client's bowel pattern to promote self-control of defecation.

A nurse is teaching a client who has benign prostatic hypertrophy and has a new prescription for finasteride. Which of the following instructions should the nurse include in the teaching? a. "Avoid drinking grapefruit juice when taking this medication." b. "Expect to see a response from the medication within one week." c. "Decreased libido is an adverse effect of the medication." d. "PSA levels will increase while taking this medication."

"Decreased libido is an adverse effect of the medication." The nurse should include in the teaching that the client may experience decreased libido as an adverse effect of the medication because of the androgenic effect on the prostate.

A nurse is caring for an older adult client who reports taking bisacodyl tablets daily. Which of the following responses should the nurse make? a. "Irregular bowel movements are an indication of poor intestinal health." b. "Excessive laxative use may cause an electrolyte imbalance." c. "Chronic use of laxatives can lead to a tear in the rectal mucosa." d. "Decrease your intake of foods high in fiber."

"Excessive laxative use may cause an electrolyte imbalance." Bisacodyl is a stimulant laxative that acts by stimulating intestinal motility and increasing the amount of water and electrolytes within the intestines; therefore, chronic use of laxatives can lead to fluid and electrolyte imbalance.

A nurse is caring for a client who reports taking bisacodyl to promote a daily bowel movement. Which of the following assessment questions should be the nurse's priority? a. "What do your bowel movements look like?" b. "How long have you been taking the bisacodyl?" c. "Do you take the bisacodyl with a glass of milk?" d. "How often do you have a bowel movement?"

"How long have you been taking the bisacodyl?" The greatest risk to this client is injury from dependency on laxatives, as bowel tone can be lost; therefore, the priority question the nurse should ask the client is how long he has been using bisacodyl.

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching? a. "It might take up to 3 days for the medication to work." b. "I will take the medication for diarrhea." c. "I should drink 4 ounces of water when I take the medication." d. "I can take this medication along with mineral oil."

"It might take up to 3 days for the medication to work." The client understands docusate sodium is a stool softener and the therapeutic effect might take up to 3 days to achieve.

A nurse is providing teaching about newborn care to a client who is 2 hr postpartum. Which of the following statements by the client indicates a need for further teaching? a. "I should keep my baby's head covered." b. "My baby's temperature will be checked rectally every hour." c. "I should place my baby on my stomach and cover her with a warm blanket." d. "My baby's bassinet should be kept away from fans and air conditioning."

"My baby's temperature will be checked rectally every hour." The newborn's axillary temperature should be checked every hour until the newborn's temperature stabilizes. Frequent rectal temperature checks are not recommended and can lead to rectal mucosal injury.

A nurse is teaching a client who has a new prescription for docusate. Which of the following information should the nurse include in the teaching? a. "Do not take this medication before bedtime." b. "Take the medication with a full glass of water." c. "Expect abdominal pain with this medication." d. "Take this medication on an empty stomach."

"Take the medication with a full glass of water." The nurse should instruct the client to take this medication with a full glass of water, unless contraindicated, to reduce the risk for constipation.

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) a. "Your provider might prescribe anticholinergic medications." b. "You should limit fluids in the evening." c. "You should restrict your intake of caffeine." d. "You might require intermittent urinary catheterization." e. "You might require an anterior vaginal repair."

"Your provider might prescribe anticholinergic medications" is correct. Anticholinergic medications suppress bladder contractions and increase bladder capacity. "You should limit fluids in the evening" is correct. Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. "You should restrict your intake of caffeine" is correct. The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant.