Elimination Ch.15

A patient with a colostomy continues to worry about odor. Which statement would be appropriate for the nurse to tell the patient about colostomy odor?

"It is caused by certain foods that can be omitted from the diet."

Bladder training instructions are being given to a patient who has a history of urinary incontinence. The nurse should give the patient which instruction?

"Void every 1.5 to 2 hours while you are awake."

A patient has a nasogastric tube inserted. What type of patient teaching should the nurse give the patient about the nasogastric tube?

- Be careful to not pull on the tube - Call the nurse if you feel as if you are going to vomit - Let the staff know if the tape holding the tube is irritating your skin

Bladder training is initiated on a patient preparing for discharge to home from an acute care setting. When should voiding times be scheduled?

- Before each meal - At bedtime - Upon waking up in the morning

The nurse administers an enema to a patient as ordered. What should be documented?

- Date - Time - Type and volume of enema - Temperature of solution - Characteristics of results - How patient tolerates procedure

A bladder retraining program for a patient in an extended-care facility should include which intervention?

- Having the patient wear clothing protectors to help decrease embarrassment. - Initiating a toilet schedule of every 2 hours during the day

The nurse is providing an informational session at a senior center on preventing constipation in older adults. Which information should the nurse include?

- Increase activity - Increase fluids - Keep daily meal journal

The nurse instructs the patient to be diligent in cleaning fecal matter from around the stoma because the fecal matter can cause which complication?

- Irritation of the stoma - Skin breakdown around the stoma

The nurse caring for a patient with an indwelling catheter should perform which actions to lower the risk for infection?

- Keep drainage bag below the level of the bed - Provide perineal care twice a day - Coil tubing on the bed - Keep the drainage system closed

A patient transferred from the post anesthesia care unit (PACU) to the postoperative unit following abdominal surgery for placement of a transverse colostomy. The patient has a nasogastric tube to medium intermittent suction. What actions can the nurse perform to verify correct placement of the nasogastric tube?

- The nurse auscultates a gurgling or a swishing sound heard with a stethoscope over the stomach when air is injected into the tube - The nurse aspirates gastric contents with the appearance of being a watery yellow or green tint with a syringe

A male patient with urinary incontinence has been using an external (condom) catheter. The nurse is evaluating the patient's technique of applying the device. Which finding would indicate the nurse should give the patient further instructions?

- Using tape around the penis to secure the device - Using a narrow width elastic bandage to wrap in a spiral pattern to secure the device - Changing the catheter after each episode of urinary incontinence

A patient is being discharged home and his peripheral IV site is to be discontinued. Following the removal of the catheter, what is the minimum length of time the nurse should hold pressure?

2-3 minutes

During insertion of a Foley catheter, the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?

Advance the catheter into the bladder

A patient with a urinary drainage system is at risk for infection. What intervention will help reduce the risk?

Avoid placing drainage bag above the level of catheter insertion

What is the correct explanation of catheter care?

Cleansing the first 2 in of the catheter with soap and water every shift

What is considered a noninvasive method of collecting urine for the incontinent patient?

Condom catheterization

The nurse is instructing the patient in performing Kegel exercises. The patient should be instructed to contract the muscles he or she would use to stop the flow of urine. What is the proper technique for performing Kegel exercises?

Contract for 10 seconds and relax for 10 seconds

The nurse is caring for a patient with a new ostomy. What is the best nursing strategy for encouraging patient self-care of an ostomy?

Encourage the patient to watch the stoma care procedure, gradually encouraging participation.

To maintain proper drainage of an indwelling catheter, it is important to perform which action?

Ensure that the collection device is below bladder level

A nurse is preparing to insert a nasogastric tube. The nurse should place the patient in which position?

High Fowler position

________ is the inability to control urine or bowel elimination and can be a psychologically distressing and socially disruptive problem, especially among older adults.

Incontinence

When explaining the difference between a colostomy and an ileostomy, the nurse explains which of the following about an ileostomy?

It drains semiliquid stool

The nurse is administering a cleansing enema. Before administering the enema, the nurse assists the patient into which position?

Left sims position

What would the nurse do to determine the correct distance to insert a nasogastric tube?

Measure from tip of the nose, to the tip of the earlobe, to the xiphoid process

A _______ tube is a flexible, hollow tube that is passed into the stomach via the nasopharynx.

Nasogastric

If the patient is suspected of having a facial impaction, which type of enema would the nurse anticipate the health care provider to order?

Oil retention enema

The nurse is preparing a patient who is to receive a cleaning enema. The patient is assisted to which position?

Sims

The nurse is administering a cleansing enema to an adult patient. The patient complains of cramping and the urge to defecate. Which nursing intervention is the best to carry out?

Slow the flow and encourage the patient to take deep breaths

When providing routine indwelling catheter care, the nurse should be most diligent in cleaning which areas?

The perineal area and 2 inches of the catheter

Before inserting a nasogastric tube, what measurement should the nurse take?

Tip of the nose to the earlobe to the xiphoid process

After a Foley catheter has been removed, the nurse should assess the patient for:

Urinary retention

A ________ is the diversion of urine away from a disease or defective bladder through a surgically created opening or stoma in the skin

Urostomy

A 5 year old patient is being seen at the pediatrician's office with a recently sprained ankle. What should the nurse take into consideration when applying cold treatment to the ankle?

Young children are more sensitive to cold