elimination
A 23-month-old child pulls a pan of hot water off the stove and spills it onto her chest and arms. Her mother is right there when it happens. What should the mother do immediately?
Place the child in a bathtub of cool water. The emergency treatment of both minor and major burns includes stopping the burning process by immersing the burned area in cool, but not cold, water. Thus, the mother should place the child in a bathtub of cool water. Applying ice directly to the burned area is inappropriate at this time because more tissue damage can result. Antibiotic ointment should not be applied to the burned area at this time because the burning process must be stopped first. Calling a neighbor for help is appropriate after the mother has placed and then removed her child from the bathtub.
A dehydrated 3 year old has vomited three times in the last hour and continues to have frequent diarrhea. The child was admitted 2 days ago with gastroenteritis caused by rotavirus. The child weighs 22 kg, has a normal saline lock in the right hand, and has had 30 ml of urine output in the last 4 hours. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with a recommendation for:
Starting a fluid bolus of normal saline. The child is dehydrated, cannot retain oral fluids, and continues to have diarrhea. A normal saline bolus should be given followed by maintenance IV fluids. Anti-diarrheal medications are not recommended for children and will prolong the illness. The child has gastroenteritis caused by a viral illness. IV antibiotics are not indicated for viral illnesses.
A 6 month old on the pediatric floor has a respiratory rate of 68, mild intercostal retractions, and an oxygen saturation of 89%. The infant has not been feeding well for the last 24 hours and is restless. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the primary healthcare provider with the recommendation for:
Starting oxygen. The infant is experiencing signs and symptoms of respiratory distress indicating a need for oxygen therapy. Sedation will not improve the infant's respiratory distress
The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about yellow and seedy stools that the infant has had since they were discharged home from the hospital. What is the best reply by the nurse?
"Soft and seedy unformed stools with each feeding are normal for this infant and will continue through breastfeeding." A soft seedy unformed stool is normal for a 4-day-old infant. Such stool may surprise the mother, because its appearance is a change from meconium the infant had at birth. The yellow and seedy stool is not diarrhea, even though it has no form. There is no need for the infant to visit the office. As long as the infant is breastfeeding, the stools will remain of this color and consistency. Brown and formed stool is common for an infant who is bottle fed or after the breastfeeding infant has begun eating food.
After teaching the parents of a neonate diagnosed with a tracheoesophageal fistula (TEF) about this anomaly, the nurse determines that the teaching was successful when the father describes the condition as which of the following?
"There is a blind upper pouch and an opening from the esophagus into the airway." Although a TEF can include several different structural anomalies, the most common type involves a blind upper pouch and a fistula from the esophagus into the trachea. Other types include a blind pouch at the end of the esophagus with no connection to the trachea and a normal trachea and esophagus with an opening that connects them. A tightened muscle below the stomach and projectile vomiting of normal amounts of formula are characteristic of pyloric stenosis. Aganglionic megacolon is a lack of autonomic parasympathetic ganglion cells in a portion of the lower intestine. Gastroschisis occurs when the bowel herniates through a defect in the abdominal wall and no membrane covers the exposed bowel.
A client has been unable to void since having abdominal surgery 7 hours ago. The nurse should first:
Assist the client up to the toilet to attempt to void. Urinary retention is common following surgery with anesthesia, childbirth, or specific medication use (eg, narcotics for pain). Clients should be assisted to an anatomically comfortable position to void prior to resorting to more invasive methods, such as intermittent or indwelling catheterization, to manage urinary retention. Difficulty voiding after delivery is expected; it is not necessary to notify the physician. While increasing fluid intake is important, it will not help the client void now.
A 30-year-old client, hospitalized with a fractured femur being treated with skeletal traction, has not had a bowel movement for 2 days. Which of the following interventions is most appropriate at this time?
Increase the client's fluid intake to 3,000 ml/day. Increasing the client's fluid intake to 3,000 ml/day, unless contraindicated, is the most appropriate action. Typically, clients who are immobilized by skeletal traction are given s... (more) Increasing the client's fluid intake to 3,000 ml/day, unless contraindicated, is the most appropriate action. Typically, clients who are immobilized by skeletal traction are given stool softeners. Treating constipation with diet, increased fluids, and stool softeners is preferred to the administration of an enema. Placing the client on the bedpan will not encourage a bowel movement. Range-of-motion movements maintain joint mobility but do not stimulate peristalsis.
The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following topics would be important for the nurse to include in the teaching plan?
Increased risk for urinary tract infections. During pregnancy, urinary tract infections are more common because of urinary stasis. Clients need instructions about increasing fluid volume intake. Plasma volume increases during pregnancy. The increase in plasma volume is more pronounced and occurs earlier than the increase in red blood cell mass, possibly resulting in physiologic anemia. Peripheral vascular resistance decreases during pregnancy, providing a relatively stable blood pressure. Hemoglobin levels decrease during pregnancy even though there is an increase in blood volume.
The nurse is reviewing the medication history of a client with benign prostatic hypertrophy (BPH). Which medication will likely aggravate BPH?
Inhaled ipratropium. Ipratropium is a bronchodilator, and its anticholinergic effects can aggravate urine retention. Metformin and buspirone do not affect the urinary system; timolol does not have a systemic effect.
A client has urge incontinence. When obtaining the health history, the nurse should ask if the client has:
Involuntary urination with minimal warning. A characteristic of urge incontinence is involuntary urination with little or no warning. The inability to empty the bladder is urine retention. Loss of urine when coughing occurs with stress incontinence. Frequent dribbling of urine is common in male clients after some types of prostate surgery or may occur in women after the development of a vesicovaginal or urethrovaginal fistula.
When preparing to administer a tap water enema, in which position should the nurse place the client?
Left Sims. When administering an enema, the nurse should position the client in a left Sims position. Placing the client in this position facilitates the flow of fluid into the rectum and colon. It also allows the client to flex the right leg forward, adequately exposing the rectal area.
The nurse instructs the client who is taking gentamicin to monitor renal function. The nurse determines that the client needs additional instruction when he makes which of the following statements?
"I should call you if I have a fever." Fever is generally not thought to be a sign of impaired renal function related to long-term use of gentamicin. The client should report signs of decreasing urinary function, such as decreased output, unusual appearance of the urine, or edema.
An adolescent girl with a seizure disorder controlled with phenytoin and carbamazepine asks the nurse about getting married and having children. Which of the following responses by the nurse would be most appropriate?
"When you decide to have children, talk to the doctor about changing your medication." Phenytoin sodium is a known teratogenic agent, causing numerous fetal problems. Therefore the adolescent should be advised to talk to the doctor about changing the medication
Nitrofurantoin, 75 mg four times per day, has been prescribed for a client with a lower urinary tract infection. The medication comes in an oral suspension of 25 mg/5 mL. How many milliliters should the nurse administer for each dose?
15 The following formula is used to calculate the correct dosage: 25 mg/5 mL = 75 mg/X mL; X = 15 mL.
Guaifenesin 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
7.5 300 mg/X = 200 mg/5 mL X = 7.5 mL.
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors is most likely of greatest significance in causing an exacerbation of ulcerative colitis?
A demanding and stressful job. Stressful and emotional events have been clearly linked to exacerbations of ulcerative colitis, although their role in the etiology of the disease has been disproved. A modified vegetarian diet or an exercise program is an unlikely cause of the exacerbation.
Which documentation tool will the nurse use to record the client's vital signs every 4 hours?
A graphic sheet.
At 24 hours of age, assessment of the neonate reveals the following: eyes closed, skin pink, no sign of eye movements, heart rate of 120 bpm, and respiratory rate of 35 breaths/minute. The nurse interprets these findings as indicating that this neonate is most likely experiencing which of the following?
A state of deep sleep. At 24 hours of age, the neonate is probably in a state of deep sleep, as evidenced by the closed eyes, lack of eye movements, normal skin color, and normal heart rate and respiratory rate. Jitteriness, a high-pitched cry, and tremors are associated with drug withdrawal. The first period of reactivity occurs in the first 30 minutes after birth, evidenced by alertness, sucking sounds, and rapid heart rate and respiratory rate. There is no evidence to suggest respiratory distress because the neonate's respiratory rate of 35 breaths/minute is normal.
A complete blood count is commonly performed before a client goes into surgery. What does this test seek to identify?
Abnormally low hematocrit (HCT) and hemoglobin (Hb) levels Low preoperative HCT and Hb levels indicate the client may require a blood transfusion before surgery.
The nurse should instruct the client with an ileostomy to report which of the following immediately?
Absence of drainage from the ileostomy for 6 or more hours. Any sudden decrease in drainage or onset of severe abdominal pain should be reported to the physician immediately because it could mean that an obstruction has developed. The ileostomy drains liquid stool at frequent intervals throughout the day. Undigested food may be present at times. A temperature of 99.8 degrees F (37.7 degrees C) is not necessarily abnormal or a cause for concern.
A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?
Assess the client's mental status regularly Central nervous system changes include such symptoms as apathy, lethargy, and decreased concentration. Seizures and coma can also occur. The nurse should assess the client's level of consciousness at regular intervals and maintain client safety. Allowing the client to express feelings related to body image changes and restricting foods high in potassium and fluid intake are all appropriate activities, but they are not related to the central nervous system changes.
A client has nephrotic syndrome. To aid in the resolution of the client's edema, the physician prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?
Blood pressure elevation. Albumin is a colloid that remains in the intravascular space, pulling fluid out of the intracellular and interstitial space. The client with nephrotic syndrome loses excessive amounts of protein, mainly albumin, in the urine. Because fluid is drawn into the intravascular space, blood pressure will increase. Crackles in the lung bases and cerebral edema are signs of circulatory overload or fluid volume excess. When edema is present in lower extremities, the skin feels cool to the touch unless an infection is present.
The nurse determines that interventions for decreasing fluid retention have been effective when the child with nephrotic syndrome demonstrates evidence of which of the following?
Decreased abdominal girth. Fluid accumulates in the abdomen and interstitial spaces owing to hydrostatic pressure changes. Increased abdominal fluid is evidenced by an increase in abdominal girth. Therefore, decreased abdominal girth is a sign of reduced fluid in the third spaces and tissues. When fluid accumulates in the abdomen and interstitial spaces, the child does not feel hungry and does not eat well. Although increased caloric intake may indicate decreased intestinal edema, it is not the best and most accurate indicator of fluid retention. Increased respiratory rate may be an indication of increasing fluid in the abdomen (ascites) causing pressure on the diaphragm. Heart rate usually stays in the normal range even with excessive fluid volume.
A client has cystitis. The nurse should further assess the client for:
Foul-smelling urine. Foul-smelling urine is indicative of cystitis. Other symptoms include dysuria and urinary frequency and urgency. Flank pain, nausea, and vomiting indicate pyelonephritis.
A 24-year-old female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of acute cystitis. When obtaining the client's history, the nurse should ask the client if she has had:
Frequency and burning on urination. The classic symptoms of cystitis are severe burning on urination, urgency, and frequent urination. Systemic symptoms, such as fever and nausea and vomiting, are more likely to accompany pyelonephritis than cystitis. Hematuria may occur, but it is not as common as frequency and burning.
A client is admitted to the recovery room after cystoscopy with biopsy. Before the nurse can discharge the client, the nurse should be sure the client:
Has voided. The nurse should verify that the client has voided prior to discharge in order to evaluate bladder infection. This procedure is not expected to affect bowel function. There may not be a need for pain medication immediately following the procedure and before discharge, but the nurse should assess the client's pain status and inform the client about the use and side effects of the medication. It is normal for the client to have hematuria because of the procedure.
The physician orders docusate sodium (Colace) 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?
Softening of the stool. Docusate sodium (Colace) is a stool softener, used to assist in bowel elimination. The client is at risk for constipation because of decreased food and fluid intake and pain from the episiotomy. Numerousanalgesics, such as ibuprofen (Motrin) or acetaminophen (Tylenol), could be used to treat episiotomy pain, helping the client achieve comfort and thus fall asleep. Oxytocin is used to contract the uterus.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1? × 1? area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
Stage II pressure ulcer. Stage I pressure ulcers appear as nonblanching macules that are red in color. Stage II ulcers have breakdown of the dermis. Stage III ulcers have full-thickness skin breakdown. In stage IV ulcers, the bone, muscle, and supporting tissue are involved. The nurse should immediately initiate plans to relieve the pressure, ensure good nutrition, and protect the area from abrasion
Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?
The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing.
A nurse is teaching a female client about preventing osteoporosis. Which teaching point is correct?
The recommended daily allowance of calcium may be found in a wide variety of foods. Premenopausal women require 1,000 mg of calcium per day. Postmenopausal women require 1,500 mg per day
The nurse should utilize SBAR communication (Situation, Background, Assessment, Recommendation) during which of the following clinical situations?
When communicating a change in a client's condition to his or her physician. SBAR communication is an increasingly common tool for interdisciplinary communication. It is not typically used during change-of-shift report nor when communicating with family members.
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
increase the frequency of the catheterizations. As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.
A nurse caring for a client with a fecal impaction should watch for:
liquid or semiliquid stools. Passage of liquid or semiliquid stools results from seepage of unformed bowel contents around the impacted stool in the rectum. Clients with fecal impaction don't pass hard, brown, formed stools because the feces can't move past the impaction. These clients typically report the urge to defecate (although they can't pass stool) and decreased appetite.
A female client reports to a nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called:
stress incontinence. Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine.
Which clinical finding should a nurse look for in a client with chronic renal failure?
Uremia Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure.
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which of the following indicates that the client is responding to the fluid resuscitation?
Urine output of 30 mL per hour Ensuring a urine output of 30 to 50 mL/hr is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.
A nurse is caring for a woman who delivered a term neonate at 6 a.m. At 4 p.m., the woman has a distended bladder and is reporting pain of 5 on a scale of 1 to 10. The nurse reviews the client's output record (see accompanying image). What should the nurse do first?
Use an in-and-out catheter to empty the bladder. The client is not emptying her bladder after repeated attempts. The nurse should now use an in-and-out catheter to empty the bladder. While the other comfort measures may be helpful, this client has not completely emptied her bladder since delivery and will be at risk for a urinary tract infection.
A client has stress incontinence. Which of the following data from the client's history contributes to the client's incontinence?
The client's history of three full-term pregnancies. The history of three pregnancies is most likely the cause of the client's current episodes of stress incontinence. The client's fluid intake, age, or history of swimming would not create an increase in intra-abdominal pressure.
A client with peripheral vascular disease has undergone a right femoral-popliteal bypass graft. The blood pressure has decreased from 124/80 to 94/62. What should the nurse assess first?
Pedal pulses. With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the d... (more) With each set of vital signs, the nurse should assess the dorsalis pedis and posterior tibial pulses. The nurse needs to ensure adequate perfusion to the lower extremity with the drop in blood pressure. IV fluids, nasal cannula setting, and capillary refill are important to assess, however, priority is to determine the cause of drop in blood pressure and that adequate perfusion through the new graft is maintained.
A 2 month old is at risk for an ileus after surgery to correct intussusception. Which of the following should be included in a focused assessment for this complication? Select all that apply.
• Assessment of bowel sounds • Characteristics of the first stool • Measurement of gastric output A postoperative ileus is a functional obstruction of the bowel. Assessment of bowel sounds, the first stool, and the amount of gastric output provide information about the return of gastric function. Measurement of urine specific gravity provides information about fluid and electrolyte status; bilirubin levels provide information about liver function, and neither of these tests need to be included in a focused assessment for ileus.
Allopurinol (Zyloprim) is prescribed for a client who has chronic gout. Which of the following comments indicates that the client understands how to take the allopurinol?
"I should drink plenty of fluids when taking allopurinol." It is important that the client force fluids to 3,000 mL/day to avoid the development of renal calculi when taking allopurinol. Allopurinol must be taken consistently to be effective in the treatment of gout. The drug should be taken after meals to avoid gastrointestinal distress. Although the client can take aspirin when taking allopurinol, both drugs can cause gastrointestinal irritation and the practice is not recommended if the client is sensitive to the medications.
Which of the following assessments should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
Auscultation of bowel sounds. Development of a paralytic ileus postoperatively is a functional obstruction of the bowel. Bowel sounds initially may be hyperactive, but then they diminish and cease. Measurement of urine specific gravity provides information about fluid and electrolyte status. The first stool and the amount of gastric output provide information about the return of gastric function.
The nurse teaches the client with chronic renal failure when to take aluminum hydroxide gel (Amphojel). Which of the following statements would indicate that the client understands the teaching?
"I'll take it with meals and bedtime snacks." Aluminum hydroxide gel (Amphojel) is administered to bind the phosphates in ingested foods and must be given with or immediately after meals and snacks. There is no need for the client to take it on a 24-hour schedule. It is not administered to treat hyperacidity in clients with chronic renal failure and therefore is not prescribed between meals.
Which statement by the parent of a child with polycystic kidney disease and stage 2 renal disease indicates the need for more teaching?
"My child will outgrow this disease." Polycystic kidney disease is a lifelong genetic disorder. A no-added salt diet is indicated to delay hypertension. Cysts may develop in other organs such as the liver. Pain manifests as the kidney disease progresses. NSAIDs may be used to treat this pain.
A client states to a nurse, "Hey sweetie, you're looking good today." Which of the following responses by the nurse is best?
"My name is Molly, and I am a nurse on the unit today." The nurse states her identity and purpose for being on the unit to clarify any misperception by the client. Saying "thank you for being so kind," "I know you are only teasing me," ... (more) The nurse states her identity and purpose for being on the unit to clarify any misperception by the client. Saying "thank you for being so kind," "I know you are only teasing me," or "I am not here to receive compliments from clients" are nontherapeutic statements and do not clarify the nurse's identity and purpose.
When preparing a client for a scheduled colonoscopy, which of the following should the nurse include?
Cleansing the bowel with laxatives or enemas. A colonoscopy is the visual examination of the large bowel using a fiberoptic endoscope inserted into the client's rectum. Typically the client will be placed on a liquid diet 24 hours before the procedure and kept NPO after midnight the night before the procedure. The bowel is cleansed through the use of laxatives and enemas. Usually, a client is placed on a clear liquid diet 24 hours before this procedure. A client does not usually receive antibiotics before a colonoscopy. However, antibiotics may be used prior to bowel surgery to decrease the risk of infection. A sedative or analgesic may be given I.V. to decrease anxiety during the procedure and promote conscious sedation. However, the nurse would not administer meperidine when preparing this client.
A client undergoing long-term peritoneal dialysis at home is currently experiencing reduced outflow from the dialysis catheter. To determine if the catheter is obstructed, the nurse should inquire whether the client has:
Constipation Constipation may contribute to reduced urine outflow, partly because peristalsis facilitates drainage outflow. For this reason, bisacodyl suppositories can be used prophylactically, even without a history of constipation. Diarrhea, vomiting, and flatulence typically do not cause decreased outflow in a peritoneal dialysis catheter.
A client with a history of cystitis is admitted to the hospital with a diagnosis of pyelonephritis. The nurse should assess the client for which of the following?
Costovertebral tenderness. Costovertebral tenderness occurs on the side of the affected kidney in pyelonephritis. Dysuria, suprapubic pain, and urine retention may occur in pyelonephritis but do not specifically support a diagnosis of pyelonephritis. Dysuria, suprapubic pain, and urine retention are symptoms of cystitis, which can lead to pyelonephritis if not treated.
Which practice should a nurse recommend to a client who has had a cesarean birth?
Coughing and deep-breathing exercises As for any postoperative client this client needs to be taught coughing and deep-breathing exercises to keep the alveoli open and prevent infection. Frequent douching isn't recomme... (more) As for any postoperative client this client needs to be taught coughing and deep-breathing exercises to keep the alveoli open and prevent infection. Frequent douching isn't recommended for any group of women and is contraindicated in women who have just given birth. Doing sit-ups at 2 weeks postpartum could damage the healing of the incision. Side-rolling exercises aren't an accepted medical practice.
Which of the following liquids should the nurse administer to a client who is intoxicated on phencyclidine (PCP) to hasten excretion of the chemical?
Cranberry Juice An acid environment aids in the excretion of phencyclidine (PCP). Therefore, the nurse should give the client with PCP intoxication cranberry juice to acidify the urine to a pH of 5.5 and accelerate excretion.
A 4 year old with a history of urinary reflux returned from surgery for bilateral ureteral re-implants 2 days ago. Which assessment finding is most concerning?
Decreased oral intake. Children with bilateral ureteral implants often have pain with urination because of bladder spasms. Some children will stop drinking to avoid the pain associated with urination, thus putting them at risk for dehydration. Intermittent bladder spasms are common after ureteral re-implant surgery and can be treated with Ditropan (oxybutynin). Small amounts of blood-tinged urine, bladder spasms, urinary frequency, and urinary incontinence are common following ureteral re-implant surgery.
Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the client's bladder, finding it distended. The nurse interprets this finding based on the understanding that the client's bladder distention is most likely caused by which of the following?
Edema in the lower urinary tract area. Urinary retention soon after delivery is usually caused by edema and trauma of the lower urinary tract; this commonly results in difficulty with initiating voiding. Hyperemia of the bladder mucosa also commonly occurs. The combination of hyperemia and edema predisposes to decreased sensation to void, overdistention of the bladder, and incomplete bladder emptying. A prolonged first stage of labor can contribute to exhaustion and uterine atony, not urinary retention. If the client had a urinary tract infection, she would exhibit symptoms such as dysuria and a burning sensation. After delivery, the uterus is contracting, which leads to less pressure on the bladder. Pressure of the uterus on the bladder occurs during labor.
A client is diagnosed with pyelonephritis. Which of the following is a priority for care now?
Ensure sufficient hydration. The nurse should ensure the client has adequate hydration. A urinary catheter is discouraged because of the risk of urinary tract infection. Monitoring of the hemoglobin level is not necessary for clients with pyelonephritis. Although antibiotics may be prescribed for long-term management and for chronic pyelonephritis, at this time the nurse should focus on helping the client maintain hydration.
The nurse has administered mannitol I.V. Which of the following is a priority assessment for the nurse to make after administering this drug?
Monitor urine output. Mannitol is an osmotic diuretic used in acute clinical situations. It increases osmotic pressure and draws fluid into the vascular space. Monitoring hourly urine output is a priority nursing assessment when administering mannitol. Electrolyte levels should also be monitored, most specifically sodium, chloride, and potassium. Calcium levels are not affected by mannitol. Bowel sounds and pupil reaction to light are not priority nursing assessments with mannitol.
Which measure included in the care plan for a client in the fourth stage of labor requires revision?
Obtain an order for catheterization to protect the bladder from trauma. Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the care plan during the fourth stage of labor.
After undergoing a barium enema, which of the following indicates that the infant has adequately evacuated the barium?
Stools that progress from clay-colored to brown. The presence of barium produces white or clay-colored stools. A change in stool color from clay-colored to normal brown is an indication that the barium has been evacuated. Presence or absence of a fecal mass does not give definitive information about the passage or retention of barium. Bowel sounds of 30 per minute suggest normal functioning but do not necessarily indicate passage of barium. A stool guaiac test is done to determine the presence of occult blood, not barium.
A nurse is instructing the client to do Kegel exercises. What should the nurse tell the client to do to perform these pelvic floor exercises?
Stop the flow of urine while urinating. By stopping urine flow during urination, the pelvic floor muscles are contracted. Tightening the leg or stomach muscles doesn't contract the pubococcygeus muscle. Pelvic squats don't tighten the pelvic floor muscles.
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
Use of accessory muscles
A client has been receiving an I.V. solution. What is an appropriate expected outcome for this client?
"The client remains free of signs and symptoms of phlebitis." is an appropriate expected outcome. Monitoring fluid intake and output is a nursing intervention. Edema and warmth are objective assessment findings. Risk for infection related to I.V. insertion is a nursing diagnosis.
A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 ml of urine output in the last 8 hours with a 1,000 ml intake. Which of the following interventions is a priority for the nurse at this time?
Assess for bladder distention. The imbalance between the client's intake and output indicates that the client may be retaining urine since the removal of his Foley catheter. The nurse's first action is to validate this assumption by assessing for bladder distention. Applying a condom catheter will not relieve urinary retention; condom catheters are meant to be used for incontinence. A urine specimen for a culture is obtained if a urinary infection is suspected, but this is not a priority at this point. Kegel exercises are helpful in controlling urinary dribbling but do not treat retention.
Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?
Establish a regular voiding schedule. Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence.
The membranes of a multigravid client in active labor rupture spontaneously, revealing greenish colored amniotic fluid. The nurse interprets this finding as related to which of the following?
Passage of meconium by the fetus. Greenish colored amniotic fluid is caused by the passage of meconium, usually secondary to a fetal insult during labor.
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make?
Take a stool softener such as docusate sodium (Colace) daily. Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation.
A client is being admitted to the hospital following an inadvertent overdose with hydrocodone (Vicodin). He reveals that he has chronic back pain which resulted from an injury on a construction site. He states, "I know I took too much Vicodin at once, but I can't live with this pain without them. You can't take them away from me." Which of the following responses by the nurse is most appropriate?
Your pain will be controlled by tapering doses of Vicodin, with other pain management strategies and medicines. Tapering doses of Vicodin, pain management strategies, and other pain control medicines are found to be the most helpful with opiate addictions resulting from chronic pain.
A client with chronic renal failure who receives hemodialysis three times a week is experiencing severe nausea. What should the nurse advise the client to do to manage the nausea?
• Have limited amounts of fluids only when thirsty. • Keep all dialysis appointments. • Eat smaller, more frequent meals. To manage nausea, the nurse can advise the client to drink limited amounts of fluid only when thirsty, eat food before drinking fluids to alleviate dry mouth, encourage strict follow-up for blood work, dialysis, and health care provider visits. Smaller, more frequent meals may help to reduce nausea and facilitate medication taking. The client should be as active as possible to avoid immobilization because it increases bone demineralization. The client should also maintain the dialysis schedule because the dialysis will remove wastes that can contribute to nausea.
When assessing a client who has just given birth, the nurse finds that the fundus is boggy and deviated to the right. What should the nurse do?
Have the client void. Having the client void can determine whether the boggy, deviated fundus results from a full bladder — the most common cause of these fundal findings. Vital sign assessment is unnecessary unless the nurse suspects hemorrhage from delayed involution. In a client who doesn't have a full bladder, the nurse should evaluate lochia characteristics to detect possible hemorrhage. If the client has a full bladder, massaging the fundus won't stimulate uterine contractions (which aid uterine involution) or prevent uterine atony — a possible cause of hemorrhage.
A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy?
Monitor the appearance, size, and number of stools. A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't indicate the effectiveness of nutritional therapy.
The nurse teaches the father of an infant hospitalized with gastroenteritis about the next step of the treatment plan once the infant's condition has been controlled. The nurse should determine that the father understands when he explains that which of the following will occur with his infant?
The infant will receive clear liquids for a period of time. The usual way to treat an infant hospitalized with gastroenteritis is to keep the infant nothing-by-mouth status to rest the gastrointestinal tract. The resulting fluid volume deficit is treated with intravenous fluids. When the infant's condition is controlled (e.g., when vomiting subsides), clear liquids are then started slowly. Formula and juice will be started once the infant's vomiting has subsided and the infant has demonstrated the ability to tolerate clear liquids for a period of time. In this situation, there is no need to test the infant's blood every day for anemia. Most likely, the infant's serum electrolyte levels would be monitored closely. Typically, an infant is placed in a private room because gastroenteritis is most commonly caused by a virus that is easily transmitted to others.
After pituitary surgery, the nurse should assess the client for which of the following?
Urine specific gravity less than 1.010. Pituitary diabetes insipidus is a potential complication after pituitary surgery because of possible interference with the production of antidiuretic hormone (ADH). One major manifestation of diabetes insipidus is polyuria because lack of ADH results in insufficient water reabsorption by the kidneys. The polyuria leads to a decreased urine specific gravity (between 1.001 and 1.010). The client may drink and excrete 5 to 40 L of fluid daily. Diabetes insipidus does not affect metabolism. A blood glucose level higher than 300 mg/dl is associated with impaired glucose metabolism or diabetes mellitus. Urine negative for sugar and ketones is normal.
To prevent catheter-associated urinary tract infection, the nurse should do which of the following?
• Provide perineal care several times a day. • Assess the client for signs of infection. • Encourage the client to drink 3,000 ml of fluids a day. Catheter acquired urinary tract infection is the most frequent type of health care-acquired infection (HAI) and represents as many as 80% of HAIs in the hospital setting. The nurse should provide meticulous perineal care, encourage the client to obtain an adequate fluid intake, and assess the client for signs of infection such as elevated temperature. It is not necessary to change the catheter daily. It is recommended that long-term use of an indwelling urinary catheter be evaluated carefully and other methods considered, if the catheter will be in place longer than 2 weeks. It is not necessary to request an order for antibiotics, because the client does not currently have an infection.
Which of the following interventions would be most appropriate for a client who has urge incontinence?
Have the client urinate on a timed schedule. Instructing the client to void at regularly scheduled intervals can help decrease the frequency of incontinence episodes. Providing a bedside commode does not decrease the number of incontinence episodes and does not help the client who leads an active lifestyle. Infections are not a common cause of urge incontinence, so antibiotics are not an appropriate treatment. Intermittent self-catheterization is appropriate for overflow or reflux incontinence, but not urge incontinence, because it does not treat the underlying cause.
To protect a client's skin under a back brace, the nurse should:
Have the client wear a thin cotton shirt under the back brace. Having the client wear a thin cotton shirt under a back brace helps to protect the skin and to keep the brace free of skin oils and perspiration. Using padding may increase pressure points. Lubricating the skin under the back brace will not provide the best protection from irritation by the brace. Powdering the skin under the back brace will not provide the best protection from irritation by the brace.
When performing a physical examination on an anxious client, a nurse should expect to find which effect produced by the parasympathetic nervous system?
Hyperactive bowel sounds The parasympathetic nervous system would produce increased GI motility, resulting in hyperactive bowel sounds, possibly leading to diarrhea. Decreased urine output, constipation, and muscle tension would result from sympathetic nervous system stimulation.
The nurse should specifically assess a client with prostatic hypertrophy for which of the following?
Difficulty starting the flow of urine. Signs and symptoms of prostatic hypertrophy include difficulty starting the flow of urine, urinary frequency and hesitancy, decreased force of the urine stream, interruptions in the urine stream when voiding, and nocturia. The prostate gland surrounds the urethra, and these symptoms are all attributed to obstruction of the urethra resulting from prostatic hypertrophy. Nocturia from incomplete emptying of the bladder is common. Straining and urine retention are usually the symptoms that prompt the client to seek care. Painful urination is generally not a symptom of prostatic hypertrophy.
While assessing a client diagnosed with dementia, the nurse notes that her husband is concerned about what he should do when she uses vulgar language with him. The nurse should:
Ignore the vulgarity and distract her. Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate.
A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should:
Increase the client's fluid intake to 3,000 ml per day. The most appropriate nursing action is to first increase the client's fluid intake to 3,000 ml per day to soften stool. A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool. Placing the client on the bedpan every 3 to 4 hours is not enough to stimulate a bowel movement. While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement.
Which of the following is the most common initial manifestation of acute renal failure?
Oliguria Oliguria is the most common initial symptom of acute renal failure. Anuria is rarely the initial symptom. Dysuria and hematuria are not associated with acute renal failure.
During assessment of an adolescent who has sustained a recent thoracic spinal injury, the nurse auscultates the adolescent's abdomen. The nurse explains to the parents that this is necessary because clients with spinal cord injury often develop which of the following?
Paralytic ileus. A thoracic spinal cord injury involves the muscles of the lower extremities, bladder, and rectum. Paralytic ileus often occurs as a result of decreased gastrointestinal muscle innervation. The nurse evaluates this by auscultating the abdomen. Because the client has a thoracic spinal cord injury, the client may not feel abdominal cramping. Additionally, auscultation would provide no evidence of cramping. Hyperactive bowel sounds would be evidenced with increased peristalsis; peristalsis would probably be diminished with this injury. Profuse diarrhea, resulting from increased peristalsis, would not be an expected finding. Diarrhea would be more commonly associated with a gastrointestinal infection.
After completing discharge instructions for a primiparous client who is bottle-feeding her term neonate, the nurse determines that the mother understands the instructions when the mother says that she should contact the primary health care provider if the neonate exhibits which of the following?
Passage of a liquid stool with a watery ring. The mother demonstrates understanding of the discharge instructions when she says that she should contact the primary health care provider if the baby has a liquid stool with a watery ring, because this indicates diarrhea. Infants can become dehydrated very quickly, and frequent diarrhea can result in dehydration. Normally, babies fall asleep easily after a feeding because they are satisfied and content. Spitting up a tablespoon of formula is normal. However, projectile or forceful vomiting in larger amounts should be reported. Bottle-fed infants typically pass one to two light brown stools each day.
A mother reports to the nurse frustration over her 7-year-old son's enuresis for the past 3 years. The mother says she has limited his evening fluids, eliminated all caffeine and soft drinks from his diet, and has had him wash his own sheets. Nevertheless, he still wets the bed almost every night. Her husband has told her he was a bed wetter as a child and thinks the son will "get over it." The mother worries that the problem could negatively affect the son's peer relationships as he grows older. Which of the following actions should the nurse take?
Suggest that the mother ask her primary health care provider about medication to deal with the enuresis. The mother's distress, the problem's length of time, and the efforts she has made to address the issue support the need for medication treatment to be considered. The absence of other symptoms negates the need for a renal workup. It is unlikely that social skills training will change the boy's nocturnal enuresis. Just waiting for the behavior to stop is likely to further tax both mother and son.
