Elimination-HESI

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?

"The enema will be given while I am sitting on the toilet."

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?

Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

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?

Left-sided lateral Sims' position

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?

Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon.

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.

-Help regulate blood pressure. -Assist to regulate acid-base balance. -Convert vitamin D to an active form. -Produce erythropoietin for red blood cell synthesis.

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

Left-sided lateral Sims' position

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?

High-fiber diet

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

It facilitates instillation of the enema solution into the colon.

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.

Palpation Inspection Percussion Bladder scanner