Elimination

A Foley catheter was placed with an urometer for a client with heart failure receiving furosemide. The output is 45 mL/hour, cloudy, and has sediment. How should the nurse interpret these findings? The furosemide is causing dehydration. Cloudy urine may be indicative of infection. The client has inadequate hourly urine output. All of the indications are within normal findings.

Cloudy urine may be indicative of infection, which is also a risk with Foley catheters. A urinalysis should be performed to confirm or rule out a urinary tract infection. The furosemide may cause dehydration, but other findings would have to be assessed, such as skin turgor. Hourly urine output should be at least 30 mL, which is being surpassed. Urine is expected to be clear amber colored; cloudy is not within expected normal appearance.

A client tells the nurse about recent recurrent episodes of bleeding hemorrhoids. What should the nurse advise the client to do to help prevent future hemorrhoidal episodes? Exercise to improve circulation Eat bland foods and avoid spices Consume a high-fiber diet and drink adequate water Use laxatives to avoid constipation and the Valsalva maneuver

Consume a high-fiber diet and drink adequate water Consuming a high-fiber diet and drinking adequate water promote regular bowel function, prevents constipation, and prevent straining, which can make hemorrhoids worse; a high-fiber diet provides bulk that stimulates peristalsis, and water promotes a soft stool. Exercise is advisable, but the purpose in this instance is to increase peristalsis, not improve circulation. Bland foods and spices are unrelated to hemorrhoids; bland foods are preferred for clients with gastric or intestinal problems. Laxatives are contraindicated because they are irritating to the bowel, decrease intestinal tone, and promote dependency. The Valsalva maneuver should also be avoided.

A client is admitted with a head injury. The nurse identifies that the client's urinary catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the mostlikely cause? Increased serum glucose Deficient renal perfusion Inadequate antidiuretic hormone (ADH) secretion Excess amounts of intravenous (IV) fluid

Inadequate antidiuretic hormone (ADH) secretion Deficient ADH from the posterior pituitary results in diabetes insipidus. This can be caused by head trauma; water is not conserved by the body, and excess amounts of urine are produced. Although increased serum glucose may cause polyuria, it is associated with diabetes mellitus, not diabetes insipidus. Ineffective renal perfusion will cause decreased urine production. While excess amounts of IV fluids may cause dilute urine, it is unlikely that a client with head trauma will be receiving excess fluid because of the danger of increased intracranial pressure.

A mother reports that her breastfed baby passes stools five times daily. How should the nurse handle this situation? Promote maternal intake of high-fiber diet. Advise the mother to shift to bottle-feeding. Administer a dose of antidiarrheal medication. Inform the mother that this is normal for infants.

Inform the mother that this is normal for infants. The normal frequency of bowel evacuation for infants who are breastfed is four to six times daily; therefore this child is normal. Maternal fiber intake does not affect passage of stools in infants. There is no need to shift to bottle-feeding. As the infant's bowel movements are normal, antidiarrheal medication is not needed.

Which ovulation stimulant is derived from the urine of postmenopausal women? Oxytocin Clomiphene Menotropins Dinoprostone

Menotropins are a standardized mixture of follicle-stimulating hormones and luteinizing hormones. These chemicals are derived from the urine of postmenopausal women. Clomiphene is a synthetic ovulation stimulant. Oxytocin and dinoprostone are synthetic uterine stimulants.

Which urinalysis finding indicates a urinary tract infection? Presence of crystals Presence of bilirubin Presence of ketones Presence of leukoesterase

Presence of leukoesterase Leukoesterases are released by white blood cells as a response to an infection or inflammation. Therefore, the presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.

What should nursing care for a child admitted with acute glomerulonephritis be directed toward? Enforcing bed rest Promoting diuresis (increased or excessive production of urine) Encouraging fluids Removing dietary salt

Promoting diuresis With the reduction of edema the child's health improves, the appetite increases, and the blood pressure normalizes. Ambulation does not have an adverse effect on this disorder; most children voluntarily restrict their activities and remain in bed during the acute phase. Fluids are not encouraged because the kidneys are inflamed and cannot tolerate large amounts of fluid. Sodium intake is decreased, not eliminated; sodium restriction is not tolerated well by children and may further decrease their appetite.

The nurse is educating student nurses about the anatomy and physiology of the kidneys. What term does the nurse explain is used for the tip of the pyramid of a kidney? Calyx Papilla Renal pelvis Renal column

Pyramids are components of renal medulla, and the tip of each pyramid is called a papilla. A calyx is a structure that collects the urine at the end of each pyramid. The renal calyces join together to form the renal pelvis. A renal column is a cortical tissue that separates the pyramids.

A client hospitalized for uncontrolled hypertension and chest pain was started on a daily diuretic 2 days ago upon admission, with prescriptions for a daily basic metabolic panel. The client's potassium level this morning is 2.7 mEq/L (2.7 mmol/L). Which action should the nurse take next? Send another blood sample to the lab to retest the serum potassium level Notify the healthcare provider that the potassium level is above normal Notify the healthcare provider that the potassium level is below normal No action is required because the potassium level is within normal limits

The healthcare provider should be notified immediately because the client's potassium is below normal. The normal potassium level range is 3.5 mEq/L to 5.0 mEq/L (3.5 mmol/L to 5.0 mmol/L). Clients on diuretic therapy require close monitoring of their electrolytes because supplemental potassium may be needed. Retesting the serum potassium level is unnecessary and will delay the treatment required by the client.

Which part of the nephron secretes creatinine required for elimination? Glomerulus Loop of Henle Collecting duct Proximal tubule

The proximal tubule of the nephron secretes creatinine and hydrogen ions. It also reabsorbs water and electrolytes. The glomerulus filters the blood selectively. The ascending loop of Henle reabsorbs sodium and chloride, whereas the descending loop of Henle concentrates the filtrate. The collecting duct reabsorbs water.

What is the maximum recommended length for enema tube insertion in an adolescent? Record your answer using a whole number in cm.

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Which signs and symptoms are characteristic of constipation? Select all that apply. Abdominal pressure Abdominal distention Stoma budding Loose feces Abdominal cramping

Abdominal pressure Abdominal distention Abdominal cramping Constipation is a condition in which the patient has difficulty in passing bowel movements. Constipation causes abdominal pressure, abdominal distention, and abdominal cramping. Accumulation of stool increases abdominal pressure, which causes stomach distention and abdominal cramping. Constipation does not cause stoma budding; budding in a stoma is normal. Loose feces are a sign of diarrhea; hard feces are a sign of constipation.

While auscultating the patient's abdomen, the nurse finds that the patient requires immediate medical attention. Which assessment finding regarding bowel sounds led the nurse to this conclusion? Absence Gurgling Sluggish Hyperactive

Absence The nurse listens to the bowel sounds by auscultation. Absence of bowel sounds indicates paralytic ileus or intestinal obstruction. These conditions are medical emergencies that require immediate medical attention. Gurgling sounds indicate normal bowel function. Sluggish sounds indicate that the patient has hypoactive bowel sounds, common after surgery. Hyperactive bowel sounds can be indicative of diarrhea. nurse must listen for five full minutes (not seconds!) before documenting absence of bowel sounds. This may seem like a long time, but the documentation is important because paralytic ileus and intestinal obstruction are medical emergencies

A nurse in the pediatric clinic is examining a toddler with suspected enterobiasis (pinworm infestation). For which first sign of an infestation should the nurse assess the child? Anal itching Scaly skin patches Maculopapular rash Bald spot on the head

Anal itching In enterobiasis the adult pinworm lays her eggs around the anal opening, producing itchy irritation. Scaly skin patches are commonly seen with eczema or dermatitis. A maculopapular rash may be seen with hookworm ( Necator americanus), not pinworm ( Enterobius vermicularis), infestation. A bald spot is produced by ringworm of the scalp (tinea capitis), a fungal infection of the skin.

A client has surgery for the creation of a colostomy. Postoperatively, what color does the nurse expect a viable stoma to be? Brick red Pale pink Light gray Dark purple

Brick red Brick red describes a stoma that has adequate vascular perfusion. Pale pink indicates inadequate perfusion of the stoma. Light gray is indicative of poor tissue perfusion. Dark purple indicates inadequate perfusion of the stoma.

A 9-year-old child with chronic kidney disease is undergoing peritoneal dialysis. For which associated complication should the nurse monitor the child? Petechiae (Tiny round brown-purple spots due to bleeding under the skin, may be in a small area due to minor trauma or widespread due to blood-clotting disorder.) Abdominal bruit (a sound, especially an abnormal one, heard through a stethoscope; a murmur.) Cloudy return dialysate Increased blood glucose level

Cloudy return dialysate The returned dialysate should be clear; cloudy return dialysate solution is indicative of infection. Petechiae do not occur during dialysis treatments. There is no danger of developing an abdominal bruit during dialysis. Dialysis does not affect the blood glucose level.

Which complication does the nurse monitor for in a pregnant patient who is taking prenatal vitamin tablets with iron? Diarrhea Flatulence Constipation Incontinence

Constipation Prenatal vitamins are rich in iron and interfere with bowel function. Iron slows down intestinal peristalsis and increases absorption of water in the colon, resulting in constipation. Diarrhea occurs due to an increase in intestinal peristalsis. Vitamins high in iron do not increase the production of gases leading to flatulence or cause fecal incontinence.

After becoming incontinent of urine, an older client is admitted to a nursing home. The client's rheumatoid arthritis contributes to severely painful joints. Which need is the primary consideration in the care of this client? Control of pain Immobilization of joints Motivation and teaching Bladder training and control

Control of pain After the need to survive (air, food, water), the need for comfort and freedom from pain closely follow; care should be given in order of the client's basic needs. Joints must be exercised, not immobilized, to prevent stiffness, contractures, and muscle atrophy. Motivation and learning will not occur unless basic needs, such as freedom from pain, are met. Although bladder training should be included in care, it is not the priority when the client is in pain.

A patient with abdominal discomfort has presence of bowel sounds that are loud, high-pitched, and rushing. Which pattern of the bowel sounds would the nurse record? Normal Hypoactive Hyperactive Tympanic note

Hyperactive bowel sounds tend to be loud, high-pitched, and rushing; they are commonly heard with diarrhea or inflammatory disorders. Normal bowel sounds occur every 5 to 15 seconds and last for 1 to a few seconds. Hypoactive sounds will be fewer than five sounds per minute. Tympanic note is not an auscultation finding; instead, it is a percussion finding.

A child with nephrotic syndrome visits the clinic for follow-up. During the visit the parent states that the child is always tired and has no appetite. The nurse notes that the child has a muddy, pale complexion. What problem does the nurse suspect? Impending renal failure Being too active in school A developing viral infection Refusal of the prescribed medications

Impending renal failure Poor appetite and decreased energy are associated with the accumulation of toxic waste; anemia accounts for the pallor. Activity does not cause these signs and symptoms. An increased temperature will probably be present, but an infection will not cause a muddy pallor. Discontinuing the corticosteroids and diuretics that are usually prescribed will probably result in recurrence of edema in a steroid-dependent child.

A nurse educates the client about the relationship between the kidneys and blood pressure. Which term should the nurse use to describe the part of the kidney that senses changes in blood pressure? Calices Glomerulus Macula densa Juxtaglomerular cells

Macula densa The macula densa, a part of the distal convoluted tubule, consists of cells that sense changes in the volume and pressure of blood. Calyces are cup-like structures, present at the end of each papilla that collect urine. The glomerulus is the initial part of the nephron, which filters blood to make urine. Juxtaglomerular cells secrete renin. Renin is produced when sensing cells in the macula densa sense changes in blood volume and pressure.

Which enema helps treat local infections? Isotonic Medication Carminative Oil-retention

Medication Medication enemas may contain antibiotics that help treat local infections. Isotonic enemas expand the colon to promote peristalsis. Carminative enemas stimulate peristalsis and provide relief from gastric distention. Oil-retention enemas lubricate the rectum and colon to make the feces softer and easier to pass.

Which medication listed in a patient's medication history may cause gastrointestinal bleeding? Cathartic Antidiarrheal opiate agent Nonsteroidal antiinflammatory drug (NSAID) Opioid

NSAID Side effects of aspirin and NSAIDs include gastrointestinal bleeding. Cathartics, antidiarrheal opiate agents, and opioids do not cause gastrointestinal bleeding.

While assessing the stoma of a patient with an ostomy, the nurse notices that the stoma is dry and black with no sign of bleeding. Which patient condition does the nurse infer from this finding? Necrotic stoma Normal stoma Fungal infection Allergic reaction

Necrotic stoma The presence of a dry and black stoma without bleeding indicates necrosis. A moist, reddish-pink stoma that is budding slightly above the skin surface is a sign of a normal stoma. A whitish area around the stoma indicates that the patient has a fungal infection. Rashes in the stoma and bleeding indicate that the patient had an allergic reaction. necrosis: Death of cells or tissue through disease or injury.

A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first? Clamp the nasogastric tube. Irrigate the tube gently with normal saline. Record the observation and continue to monitor the drainage from the tube. Reduce the pressure of the suction and record observations of the drainage characteristics.

Some bright red blood at this point is an expected finding that should be monitored; large amounts of blood or bleeding should be reported immediately. Clamping the nasogastric tube is contraindicated; secretions will accumulate and cause pressure on the suture line. Also, clamping the tube prevents observation of gastric drainage. If the tube is draining, there is no need to irrigate; also, irrigations are traumatic. Reducing suction pressure allows secretions to accumulate and causes pressure on the suture line.

The nurse finds that a patient complaining of constipation has a history of a myocardial infarction and is taking antianginal drugs. Which nursing intervention would help prevent cardiac complications in this patient? Obtain and record daily weights from the patient Instruct the patient not to strain while defecating Explain how to ignore the urge to defecate Encourage the patient to consume lukewarm liquids

Straining may cause bradycardia by stimulating the Valsalva maneuver. This can trigger another myocardial infarction. The Valsalva maneuver is performed by holding one's breath while bearing down. This closes the windpipe and increases intrathoracic pressure. This maneuver causes a fast rise in blood pressure followed by a fall in arterial blood pressure. This can result in dizziness, blurred vision, and fainting. A patient with diarrhea should be weighed daily to monitor fluid and electrolyte balance and prevent life-threatening fluid loss. Ignoring the urge to defecate allows increased water absorption in the colon, making feces hard and difficult to expel, and may lead to straining. Warm and cold liquids, rather than lukewarm liquids, stimulate peristalsis and aid in defecation, thus reducing the need to strain while defecating.

A school-aged child with newly diagnosed acute lymphocytic leukemia (ALL) is to undergo induction therapy with prednisone, vincristine, and asparaginase. After several days the child becomes constipated. What does the nurse suspect as the cause? Diet, which lacks bulk Inactivity, which results from illness Vincristine, which decreases peristalsis Prednisone, which causes gastric irritability

Vincristine, which decreases peristalsis Constipation, which may progress to paralytic ileus, is a side effect of vincristine. Lack of bulk and inactivity each may contribute to constipation, but neither is the primary cause of this child's constipation. Prednisone may cause nausea and vomiting, but it does not cause constipation.

A client begins therapy with a new medication. One month later the client notices blood in the urine. Which drug does the nurse anticipate as the cause? Warfarin Nifedipine Nitrofurantoin Phenazopyridine

Warfarin is an anticoagulant medication and could result in blood in urine, a condition known as hematuria. Nifedipine is a calcium channel blocker that could affect the ability of the urinary bladder or sphincter to contract and relax normally. Nitrofurantoin is used to treat urinary tract infections but can cause alteration in urine color to a dark yellowish-brown. Phenazopyridine, a bladder analgesic used to treat pain associated with urinary tract conditions, changes the color of urine to orange or red.

A 3-year-old preschooler has been hospitalized with nephrotic syndrome. What is the best way for the nurse to evaluate fluid retention or loss? Measuring the abdominal girth daily Having the child urinate in a bedpan Testing the child's urine for proteinuria Weighing the child at the same time each day

Weighing the child at the same time each day Comparison of daily weights is the most accurate way to assess fluid retention or loss. Having the child urinate in a bedpan is difficult for a child of this age, and the findings will not be accurate. Measuring the abdominal girth daily is way to assess the degree of ascites; it indirectly measures fluid retention. Assessment of urine for protein gives information about the disease process, but not about the amount of fluid retention.