Prepu Questions: Elimination

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening?

50-year-old client with a family history of polyps explanation: The nurse will teach that the 50-year-old client with a family history of polyps should consider a colonoscopy screening. Screenings should start at 50 years old and continue every 10 years thereafter. Other answers are incorrect.

The nurse is replacing a client's ileostomy appliance and has identified that the diameter of the stoma is 3.5 cm. The nurse has trimmed the flange of the new appliance to a diameter of 7 cm. What will be the most likely outcome of the nurse's action?

A risk that the peristomal skin will become excoriated explanation: An appliance that is too large will expose peristomal skin to digestive enzymes, leading to skin breakdown. It will not fit as securely as it should, but this does not necessarily mean that it will need to be changed daily. Prolapse is not related to the way that the appliance is sized or trimmed.

The nurse is caring for a client with a brain tumor when the client begins to vomit. Which intervention should the nurse do first?

Assess for other signs/symptoms of increased intracranial pressure. explanation: The tumor may be causing increased intracranial pressure. Vomiting, with or without nausea, is a common symptom of increased intracranial pressure and/or brain stem compression. The nurse's first action is to assess for other signs/symptoms of increased intracranial pressure. Once the assessment is completed, the nurse should contact the physician if indicated by the findings.

A client has a transurethral resection of the prostate to treat benign prostatic hyperplasia. The client returns to the room with continuous bladder irrigation and reports bladder pain. What is the priority nursing action?

Assess irrigation catheter for patency and drainage. explanation: Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After confirming catheter patency, the nurse should administer an analgesic, such as morphine sulfate, as prescribed. The intake and output is part of the assessment, but the patency of the catheter is the priority. Notifying the healthcare provider is not necessary unless the pain is severe or unrelieved by the prescribed medication.

A male client who has had outpatient surgery is unable to void while lying supine. Which intervention would be most effective in assisting the client to urinate?

Assist the client to a standing position. explanation: Helping clients assume their usual voiding positions may be all that is necessary to resolve an inability to void. If male clients cannot void lying down, the nurse will encourage them to void while standing at the bedside, unless this is contraindicated. While running water often helps relax clients so voiding can occur, it is not addressing the clients true need. Telling the client that he needs to void prior to discharge is putting stress on performing the activity, which is counterproductive. Asking the spouse to assist with holding the urinal may also make the client uncomfortable.

A client comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. Which assessment techniques and diagnostic studies should the nurse use?

Bowel sounds and stool sample explanation: Outbreaks of food poisoning can result in severe gastrointestinal symptoms. Severe abdominal cramping followed by watery or bloody diarrhea may signal a microbial infection, which can be confirmed by a stool sample. The nurse will assess bowel sounds as well as obtain a history from the client. Routine urinalysis can be used to assess the urine but not the gastrointestinal system. Chest x-rays and sputum samples, as well as lung sounds, are used to assess the respiratory system.

During the well-child checkup for 2-year-old twins (one boy, one girl), their mother asks the nurse about preparing to toilet train the children. What information can be provided to the parent? Select all that apply.

Daytime incontinence is not a concern while toilet training Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training. Children old enough to undress themselves will have increased abilities to toilet train. explanation: Beginning sometime between 2 and 3 years of age, parents should to watch for signs that a child may be ready for toilet training. These signs include staying dry for two hours at a time or dry after naps, as well as being able to walk to the bathroom and ability to undress themselves. Most children will achieve daytime urinary control by 3 to 4 years of age. Sometimes, toddlers need to experience outdoor playtime without diapers to see what happens when they experience bladder fullness, followed by urethral relaxation and bladder emptying. They begin to understand the relationship between bladder fullness and voluntary bladder emptying and are ready for toilet training. Nighttime continence may not occur until 4 or 5 years of age.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sound explanation: If the client has a nasogastric tube in place, disconnect it from the suction during this assessment to allow for accurate interpretation of sounds. Allowing the low intermittent to continue during the assessment will interfere with the auscultation of the sounds. Disconnect of the tube can occur immediately and not for 1 hour prior to the assessment.

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem?

Discuss the use of protective undergarments to avoid embarrassment from incontinence. explanation: The nurse will promote the client's self-esteem by openly discussing adult undergarments. The client has no other health problems, and can benefit by learning how to self-manage this concern. Encouraging the client to tell family members does not support the client's desire to refrain from telling others about this issue. The client does not need referral to a urologist at this time. Reassuring the client that others have this concern is nontherapeutic and does not directly meet the client's concern.

The nursing assistant reports that a client on furosemide has voided 2000 mL in a 24-hour period. What is the appropriate nursing action?

Document the finding as normal. explanation: Voiding 500-3000 mL/day is considered normal. The nurse should simply document the finding. The other actions are not necessary

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client?

Regular toileting routine explanation: The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.

Sympathomimetics have which of the following effects on the body?

Relaxation of bladder wall explanation: Sympathomimetics mimic the sympathetic nervous system, causing increased heart rate and contractility, dilation of bronchioles and pupils, and bladder wall relaxation.

As the nurse is preparing an immunization for a male client 2 years of age, his mother discovers that he has soiled his underpants. She scolds him and calls him a "bad boy" because he "dirtied" his underwear. The nurse gives the immunization and provides some education to the mother about appropriate expectations for this age group. The nurse knows that according to Erikson's theory for this client's age group, he is at risk to develop which of the following?

Shame and doubt explanation: According to Erikson, the toddler's task is to achieve autonomy versus shame and doubt. If the caregivers are overprotective or have expectations that are too high (such as the client's mother), shame and doubt, as well as feelings of inadequacy, might develop in the child. During the initiative versus guilt stage, children begin to assert their power and control over the world through directing play and other social interaction. Industry versus inferiority is the fourth stage of Erik Erikson's theory of psychosocial development. The stage occurs during childhood between the ages of approximately six and eleven. Children are at the stage where they will be learning to read and write, to do sums, to do things on their own. Intimacy versus isolation is the sixth stage of Erik Erikson's theory of psychosocial development. This stage takes place during young adulthood between the ages of approximately 19 and 40. During this period, the major conflict centers on forming intimate, loving relationships with other people.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway. explanation: The tube is in the airway if the client shows signs of distress and cannot speak or hum. Excessive coughing and gagging may occur if the tube has curled in the back of throat. A vasovagal reaction is typically manifested by lightheadedness and fainting, not by gasping and an inability to vocalize. There is no indication that the client is forcefully resisting the procedure.

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?

The client has an enlarged prostate. explanation: Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.

The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care." explanation: With a diagnosis of altered body image, a nurse would create interventions for the client becoming more comfortable with the surgical change. When the client is willing to look at the stoma, makes neutral or positive statements about the ostomy, and begins to assist with their care demonstrates that the client is accepting of the body image change that occurred. If the client takes prescribed antidepressants and uses spray deodorant several times an hour means that the has not accepted the change in their body or rather is in denial of the surgical change.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client pt. 2?

The client will have to wear an external appliance to collect urine. explanation: An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter?

The client will have to wear an external appliance to collect urine. explanation: An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

A nurse is preparing a client for colon surgery. Which teaching should the nurse provide first to prepare the client for what to expect after surgery?

The nurse will listen to the bowel sounds regularly explanation: Direct manipulation of the bowel during abdominal surgery inhibits peristalsis, which may cause a condition termed paralytic ileus. This temporary stoppage normally lasts 24 to 48 hours. Nurses will listen for bowel sounds as part of regular assessments. Fluids will be encouraged, but measuring fluid intake, not urinary output, will determine adequate fluid intake. The pulse will be measured to establish a baseline and observe for indicators of change. Assessing skin turgor can help to assess for dehydration.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the mostlogical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination explanation: There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning explanation: While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing?

hemorrhoids explanation: Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. This is unrelated to paralytic ileus or diarrhea; hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Constipation is a condition in which there is difficulty in emptying the bowels, usually associated with hardened feces. Diarrhea is a condition in which feces are discharged from the bowels frequently and in a liquid form. Paralytic ileus is an obstruction of the intestine due to paralysis of the intestinal muscles.

A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?

stress explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?

"I make sure to limit how much I drink so that I don't have accidents." explanation:

What is the micturition reflex?

The act of bladder contraction and perceived need to void. explanation: Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition.

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend?

If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. explanation: If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. The health care provider may order the nurse to replace the NG tube. If epistaxis occurs with removal of the NG tube, occlude both nares until bleeding has subsided and ensure the client is in an upright position. Petroleum jelly is not used to address pain during removal. The nurse cannot independently reinsert the NG tube.

The client who has diabetes is scheduled for an abdominal CT scan. The nurse is preparing the client for the test. What assessments and instructions would the nurse perform? Select all that apply.

Instruct the client to withhold metformin prior to the CT scan. Ask the client about allergies, particularly iodine, shellfish, and/or IV contrast. Obtain and review BUN and creatinine levels prior to the CT scan. explanation: In preparing the client for a CT scan of the abdomen, the nurse would ask about allergies. Clients may have experienced an allergic reaction to iodine, shellfish, and/or IV contrast. The nurse would assess for renal impairment, which would be demonstrated in the BUN and creatinine levels. If the client is taking metformin, a common oral hypoglycemic medication, the client would be instructed to withhold it until the BUN and creatinine are assessed again after the test. The client is NPO for 4 hours prior to the CT scan, and informed consent is required for the CT scan.

The nurse observes the unlicensed assistive personnel (UAP) serving a food tray to a client with diarrhea. The nurse would intervene if which food item is included on the client's tray?

Sliced red apples explanation: Fresh fruits are high in fiber and should be avoided in a low-fiber diet. Refined grains (cream of wheat), eggs, and fish (steamed haddock) are low in fiber.

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure?

Position the client in a supine position. explanation: Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.

A child has been brought to an urgent care clinic. The parents state that the child is "not making water." When taking a history, the nurse learns the child had a sore throat about 1 week ago but seems to have gotten over it. "We [parents] only had to give antibiotics for 3 days for the throat to be better." The nurse should suspect the child has developed:

acute postinfectious glomerulonephritis. explanation: The classic case of poststreptococcal glomerulonephritis follows a streptococcal infection by approximately 7 to 12 days: the time needed for the development of antibodies. The primary infection usually involves the pharynx (pharyngitis), but can also result from a skin infection (impetigo). Oliguria, which develops as the GFR decreases, is one of the first symptoms.

An infant is born with spina bifida. She may have:

alterations in urinary elimination. explanation: Congenital malformations of the central nervous system may cause serious alterations in urinary elimination.

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?

"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." explanation: Elimination patterns vary widely among individuals, and the expectation of a daily bowel movement is not realistic for many healthy people. This client may not require pharmacologic interventions.

The nurse is providing education for a client with frequent constipation about the use of bisacodyl to improve defecation. What statements made by the client indicate that the teaching is effective? Select all that apply.

"Bisacodyl will cause irritation of the intestinal mucosa and increase water in the stool." "It will improve defecation by increasing motility." "I should increase my fluid intake to help with my bowel movements". explanation: Stimulant laxatives, such as bisacodyl and senna, improve defecation by increasing motility through irritation of the intestinal mucosa and increased water in the stool. Bulk-forming laxatives such as psyllium hydrophilic mucilloid work by absorbing water into the intestine to soften the stool and increasing stool bulk, but bisacodyl is not considered a bulk forming laxative. Bisacodyl is not a stool softener.

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply.

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?" explanation: The nurse will ask about new medications because these can often cause diarrhea; what the client's normal bowel habits are like, to establish a baseline; and whether the client is using laxatives, which can contribute to diarrhea. Rectal fullness and stool that is difficult to pass are associated with constipation.

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching?

"Having sexual relationships does not put a woman at risk for developing a UTI explanation: During sexual intercourse, bacteria from the perineal area may travel into the urethra and urinary bladder. The spermicide used with the diaphragm decreases the vagina's normally protective flora. The glucose in the urine acts as an excellent medium for bacteria to proliferate in the client with diabetes mellitus. Older adults are predisposed to development of urinary tract infections due to the physiologic changes associated with aging.

A school nurse is educating a class of female middle school students on how to promote urinary system health. Which statement by one of the girls indicates understanding?

"I will wipe from front to back after going to the toilet." explanation: Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include drying the perineal area after urination or defecation from the front to the back (or from urethra to rectum). Wearing tight pants can trap microorganisms. Drinking water will has no bearing on how long microorganisms stay in the body. Children should always inform parents of any symptoms of illness, but this does not address how to promote urinary health

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

"Let me talk to your health care provider about a condom catheter." explanation: The nurse will support the client's autonomy by investigating other options, such as a condom catheter. It is nontherapeutic to discount the client's concern or to tell the client that this is the only catheterization option.

A female client is diagnosed with a urinary tract infection (UTI) and states this is her second one in the last 6 months. In teaching the client about health promotion, the nurse would include which statement?

"Try to urinate immediately after sexual intercourse." explanation: The female client who has repeated UTIs needs health promotion teaching to avoid reoccurrence of these. Urinating immediately after sexual intercourse and drinking an adequate amount of water (eight 8 to 10 oz glasses per day) are important in prevention of UTIs. Showers (rather than tub baths) and cleaning the perineal area from front to back are also measures to help prevent UTIs.

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr explanation: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a).

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis?

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate explanation: The most appropriate nursing diagnosis addresses the client's fecal incontinence, related to loss of sphincter control innervation.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls. explanation: Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

Check health record for provider's order. explanation: The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after the order is confirmed.

A client could experience increased urination when using which classification of medication?

Cholinergic agents explanation: Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination. Analgesics act to relieve pain. Central nervous system depressants are medicines that include sedatives, tranquilizers, and hypnotics. These drugs can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders. Stool softeners makes bowel movements softer and easier to pass.

The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?

Clamp the tube for a brief period and resume at a slower rate. explanation: Cramping can occur with the administration of a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion, possibly at a slower rate. Other choices are incorrect, as these do not facilitate administration of the enema while providing comfort measures.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

Which client would the nurse consider having the highest risk for developing a urinary tract infection?

Client with obstructed urinary outflow from a kidney stone explanation: Factors that contribute to the development of ascending infections of the urinary tract are outflow obstruction, catheterization and urinary instrumentation, vesicoureteral reflux, sexually active women, postmenopausal women, and neurogenic bladder.

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Encourage fluid intake. explanation: Conservation of fluid by the body during states of underhydration, fever, and diaphoresis results in the production of concentrated urine that is dark in color. A sign of overhydration would be very light or clear urine. Adequate fluid intake would correspond with pale yellow and clear urine. Signs of urinary tract infection include cloudy urine or urine containing blood or blood cells.

An older male comes to the clinic with the chief report of having difficulty voiding. The physician diagnoses him with a lower urinary tract obstruction and stasis. What should the nurse suspect to be the most frequent cause of this client's problem?

Enlargement of prostate gland explanation: In men, the most important acquired cause of urinary stasis and urinary obstruction is external compression of the urethra caused by the enlargement of the prostate gland. Bladder tumors, gonorrhea, and kidney infections can cause the same symptoms—but the most important and frequent cause is benign prostatic hyperplasia (BPH).

The nurse is caring for a client with a condition of deficiency of antidiuretic hormone (ADH). When assessing the client, which finding does the nurse anticipate?

Excessive urine output explanation: ADH regulates the ability of the kidneys to concentrate urine. When ADH is present, the water that moved from the blood into the urine filtrate in the glomeruli is returned to the circulatory system, and when ADH is absent, the water is excreted in the urine. Pathologically, deficiency of ADH leads to polyuria and dehydration.

The nurse is caring for a thyroid cancer client following oral radioactive iodine treatment. Which teaching point is most important?

Flush the toilet twice after every use. explanation: Iodine 131 is a systemic internal radiation that is excreted through body fluids, especially urine. Flushing the toilet twice after every use will avoid the exposure of others to radioactive exposure. Shielding the throat area is not effective because this form of treatment is systemic. Preparing food separately is not necessary, but use of separate eating utensils will be necessary for the first 8 days.

A nurse is providing home care for a client with fecal incontinence. Which suggestions should the nurse give the client and family when managing fecal incontinence? Select all that apply.

Have the client use moisture-proof undergarments. Ask the client to monitor the pattern of incontinence. Eat nutritious foods regularly. explanation: The nurse can suggest that the client manage fecal incontinence by eating nutritious foods regularly and using moisture-proof undergarments to protect clothes and bed linen. Asking the client to monitor the pattern of incontinence helps to determine whether it occurs at a similar time each day. Limiting fiber intake is inadvisable and will not help resolve fecal incontinence. Asking the client to pull the abdomen inward and exhale induces forced coughing.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is

Impaired Skin Integrity related to urinary bladder infection and dehydration explanation: Impaired Skin Integrity related to urinary bladder infection and dehydration would be the appropriate nursing diagnosis. The nursing concern is his excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary Tract Infection is not a nursing diagnosis, rather a medical diagnosis. The impaired skin integrity is not related to functional incontinence. Urinary Incontinence is not a nursing diagnosis, rather a medical diagnosis.

Gastrin has which of the following effects on gastrointestinal (GI) motility?

Increased motility of the stomach explanation: Gastrin has the following effects on GI motility: increased motility of the stomach, excitation of the colon, relaxation of ileocecal sphincter, and contraction of the gastroesophageal sphincter.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include?

Keep muscles contracted for at least 10 seconds. explanation: Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. Which postoperative procedure should the nurse perform?

Maintain skin and stoma integrity explanation: The most important postoperative nursing management is to maintain skin and stoma integrity to avoid further complications, such as skin infections and urinary odor. Determining the client's ability to manage stoma care, showing photographs, and suggesting a visit to a local ostomy group would be a part of the preoperative procedure.

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings explanation: The assessment is indicative of hospital-acquired catheter infection associated with the CVC. The medical provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Checking for blood return is not indicated and access to the CVC used for hemodialysis should not be attempted without a prescription to do so from the health care provider.

A client, aged 75, is diagnosed with a renal disease and administered nephrotoxic drugs in normal doses. The nurse is aware that it is important to observe the client closely for any changes in renal status. Which of the following measures may help a nurse determine a change in renal status?

Observing the client's urinary output. explanation: Nephrotoxic drugs are not administered to a client with renal disease unless the client's life is in danger and no other therapeutic agent is of value. Since the client is given nephrotoxic drugs in normal doses, observing the client's urinary output can help the nurse determine a change in the renal status. Observing the client's fluid intake and noting the color of skin and nail beds do not help a nurse determine a change in the renal status. Checking for a thrill or a bruit daily is performed for a client with a vascular access device.

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last?

Palpation explanation: The abdominal assessment should be performed in the following sequence: inspection, auscultation, percussion, palpation.

Which medication may be ordered to relieve discomfort associated with a UTI?

Phenazopyridine explanation: Phenazopyridine is a urinary analgesic ordered to relieve discomfort associated with UTIs. Nitrofurantoin, ciprofloxacin, and levofloxacin are antibiotics.

The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next?

Shower, bathe, or wash peristomal area with mild soapy water.

A client who has undergone colostomy surgery

Suggest fluid intake of at least 2 L/day explanation: The nurse should suggest a fluid intake of at least 2 L/day to help the client avoid constipation. The nurse should also offer prune or apple juice because they promote elimination. The nurse should encourage the client to eat regular meals. Dieting or fasting can decrease stool volume and slow elimination. The nurse should instruct the client to keep a record of food intake in case of diarrhea, because this helps identify specific foods that irritate the gastrointestinal tract.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal?

The client is acutely confused and has been diagnosed with delirium. explanation: A client who is acutely confused is likely unable to manipulate a urinal effectively. Kidney stones, BPH, and previous catheterizations do not preclude the use of a urinal.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse?

The graduate places the client in Fowler's position. explanation: Placing the client in Fowler's position during an enema will cause the solution to remain in the rectum; expulsion of the solution happens rapidly with minimal cleansing accomplished. The solution should be retained until the desired results are achieved. The solution should not be too hot or too cold, but administered at room temperature. Most people are uncomfortable about discussing the intestinal tract and bowel elimination, so this is an opportune time to discuss it.

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation. explanation: The correct sequence for an abdominal assessment is inspection, then auscultation (done before palpation because palpation may disturb normal peristalsis and bowel motility), followed by percussion and palpation. The client should urinate before assessment and the knees should be flexed with the abdomen during the examination.

T/F: Use of an indwelling urinary catheter leads to the loss of bladder tone?

True explanation: People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.

Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk?

Wearing disposable gloves explanation: The nurse is responsible for obtaining the specimen according to facility procedure, labeling the specimen, and ensuring that the specimen is collected safely and transported to the laboratory in a timely manner. Use of medical aseptic techniques is imperative. Always wear disposable gloves when any contact or handling of a stool specimen is likely. While all actions help prevent contact with the stool, and thus help minimize the risk for injury to the staff, the use of disposable gloves has the greatest impact by being a barrier against direct contamination of the skin by the stool itself.

The proliferation of Clostridium difficile causes:

antibiotic-associated diarrhea. explanation: Normal intestinal flora inhibit the growth of Clostridium difficile. When broad-spectrum antibiotics, especially third-generation cephalosporins, are administered, normal flora is altered and C. difficile can proliferate and release toxins that cause antibiotic-associated diarrhea.

When the nurse performs a Hemoccult test on a stool specimen, blood in the stool will change the color on the test paper to:

blue explanation: Blue is a positive diagnostic finding, indicating the presence of blood in the stool sample.

The nurse is evaluating stool characteristics of an adult client. Which of the following would describe a normal stool? Select all that apply.

dark brown light brown explanation: The nurse identifies that normal stool varies in color from light to dark brown. Black, clay (tan), and yellow are considered abnormal colors for adult stool.

A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?

hypertonic saline explanation: The nurse will gather a hypertonic solution, which is used to irritate local tissue and draw water into the bowel. Mineral oil is used for lubrication and softening of stool. Tap water is used to distend the rectum and moisten stool; soap and water are used to do the same plus irritate local tissue.

A physician orders an enema to effect rapid colonic emptying in a client who is experiencing severe abdominal cramping due to constipation. Which type of solution would be best suited to this client's needs?

large-volume cleansing enema with hypotonic solution explanation: Large-volume cleansing enemas are known as hypotonic or isotonic, depending on the solution used. Hypotonic (tap water) and isotonic (normal saline solution) enemas are large-volume enemas that result in rapid colonic emptying. Oil-retention enemas: lubricate the stool and intestinal mucosa, making defecation easier.

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema?

left side-lying explanation: When administering a cleansing enema, the client is most often positioned in a left side-lying (Sims') position. Prone is lying flat, especially face downward. Visualization of the rectum is acceptable but insertion of the enema is difficult. The supine position means lying horizontally with the face and torso facing up, and this is not helpful for inserting an enema as a nurse cannot visualize the rectum. The right side-lying position is used for positioning of a client, not for an enema.

A client has a suspected bladder tumor. What is the most common first symptom of a malignant tumor of the bladder?

painless hematuria explanation: The most common first symptom of a malignant tumor of the bladder is painless hematuria. Additional early symptoms include UTI with symptoms such as fever, dysuria, urgency, and frequency.

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter explanation: To be effective, a suppository must be inserted past the internal sphincter, which is about the distance of the finger of insertion.

The nurse is caring for a client with constipation related to a small bowel obstruction. How will the nurse document this finding?

secondary constipation explanation: The nurse will document this finding as secondary constipation, which is a consequence of a pathologic disorder. The other answers do not correctly describe the client's condition.

A nurse has auscultated the abdomen in all four quadrants for 5 minutes and has not heard any bowel sounds. How would this be documented?

"All four abdominal quadrants auscultated. Inaudible bowel sounds." explanation: In the correct response, the nurse has documented what was done during the assessment and has noted that bowel sounds are inaudible. "Auscultated abdomen for bowel sounds. Bowel not functioning" is not appropriate as the nurse has diagnosed that the bowel is not functioning which is a medical diagnosis. The documentation lacks the assessment. "Bowel sounds auscultated. Client has no bowel sounds" is not appropriate does not indicate where bowel sounds were auscultated. "Client may have bowel sounds, but they can't be heard" is a subjective statement and does not document the assessment.

After teaching a patient who is receiving ferrous sulfate about the drug therapy regimen, which patient statement indicates that the teaching was successful?

"My stools might turn dark or green." explanation: The patient needs to know that his stools may become dark or green. Small frequent meals with snacks can help minimize nausea and GI upset associated with this drug. The patient may take the drug with meals as long as those meals do not include eggs, milk, coffee, and tea. Constipation is possible, so the patient needs to increase the fiber in his diet.

The nurse needs to collect stool for occult blood testing from an 8-month-old client. The parent asks if the specimen for testing can be collected from the child's diaper. What is the best response by the nurse?

"Only if the stool has not been contaminated by urine." explanation: Stool can be collected from a diaper for occult blood testing only if the stool has not been contaminated by urine. It does not matter whether the diaper is disposable or cloth. The type of developer does not make a difference as all are used to test for occult blood.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg explanation: The nurse will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.

A woman in her late 30s has been having unusually heavy menstrual periods combined with occasional urine and stool leakage over the past few weeks. Upon further enquiry, she reveals that she also has postcoital pain and bleeding. To which diagnosis will the investigation most likely lead?

Cervical cancer explanation: The client's symptoms are those of cervical cancer. Symptoms of cervical cancer include abnormal vaginal bleeding and persistent yellowish, blood-tinged, or foul-smelling discharge. Clients may complain of postcoital pain and bleeding, bleeding between menstrual periods, and unusually heavy menstrual periods. If the cancer has progressed into the pelvic wall, the Clients may experience pain in the flank regions of the body.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas. explanation: Vegetables such as cabbage, cucumbers, and onions are commonly known for producing gas. By introducing fiber over a period of time, the client can get used to fiber intake and note which foods cause more gas. Flatulence, or flatus, results from swallowing air while eating or sluggish peristalsis. Drinking soft drinks can increase gas and have no effect on fiber breakdown in the body. Another cause is the gas that forms as a byproduct of bacterial fermentation in the bowel. Protein does not produce gas that leads to flatus.

A client is in the hospital for the treatment of peptic ulcer disease. The client reports vomiting and a sudden severe pain in the abdomen. The nurse then assesses a board-like abdomen. What does the nurse suspect these symptoms indicate?

Perforation of the peptic ulcer explanation: Signs and symptoms of perforation include the following: Sudden, severe upper abdominal pain (persisting and increasing in intensity), which may be referred to the shoulders, especially the right shoulder, because of irritation of the phrenic nerve in the diaphragm; vomiting; collapse (fainting); extremely tender and rigid (board-like) abdomen; and hypotension and tachycardia, indicating shock.

Which urinary care teaching will the nurse provide to a young adult female client?

Refrain from douching unless ordered by a health care provider. explanation: Douching is not recommended unless ordered by the health care provider. Female clients should be taught to wipe from the urinary area towards the rectum to decrease the risk for introducing pathogens into the urethra. Straining is not appropriate. Water should be consumed throughout the day, not just in the morning and evening.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma?

Use water and mild soap. explanation: The nurse will teach the client to use water and mild soap to cleanse the stoma. Water only will not provide cleansing; an alcohol-based sanitizer will dry the stoma; mineral oil is not appropriate for cleansing.

The health care provider prescribes a high-fiber diet for a client to promote bowel elimination. Which foods, selected by the client, would indicate to the nurse that the client can identify high-fiber foods?

Whole wheat spaghetti and broccoli explanation: To promote bowel elimination, the client should consume 20 to 35 g of fiber daily. Foods high in fiber include fresh fruits and vegetables, bran, and whole grains. Cream of wheat is refined cereal and fiber has been removed from apples because of cooking. Other foods low in fiber include soda crackers, chicken noodle soup, tea, and flavored water.

A client wishes to increase fiber to promote more regular bowel movements. Which food will the nurse recommend that the client consume?

brown rice explanation: The nurse will recommend brown rice, a food that is high in dietary fiber. Other selections listed do not contain high fiber.

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake. explanation: Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts

A student nurse studying human anatomy knows that a structure of the large intestine is the:

cecum explanation: The small intestine consists of the duodenum, jejunum, and ileum. The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum.

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

stress explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Other types of incontinence have different causative factors.

The nurse is caring for a male client with weakness who has been ordered to stay on bed rest for several days. Which method for urinary elimination does the nurse provide?

urinal explanation: The client with weakness who has been ordered to stay on bed rest will benefit from use of a urinal. The client should not be moved to the bedside commode or regular bathroom. A fracture pan may be useful for bowel movements.

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states, "I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse?

"Children vary in their readiness but daytime bowel control may be attained at 30 months." explanation: Successful bowel training also includes awareness by the toddler of the need to defecate, the ability to communicate this need, the wish to please the significant person involved in bowel training, and praise and reinforcement for the toddler's successful behavior. Daytime bowel control is normally attained by 30 months of age, but the age varies with each child. Informing the parent that pressure is too much for the child and parent may make the parent feel guilt and should be avoided. The nurse should never tell the parent that something is wrong if the child is not toilet trained since this may vary with all children. The nurse is being dismissive when telling the parent that there is nothing to worry about.

A client with urinary incontinence is prescribed incontinence briefs. Which factors should be included in the client education the nurse provides?

"Cleanse the skin each time you change the briefs." explanation: Clients need to change the protective pads or briefs frequently to avoid odor and to prevent skin irritation from prolonged exposure to moisture. Clients should not use cologne or perfume to mask odor, as it may irritate the perineal area. Clients wearing absorbent products should bathe at least daily. Each time the product is changed, the perineal area should be cleansed and examined for any areas of irritation. To reduce the incidence of incontinence, the client should use the bathroom at least every 2 hours during waking hours.

A mother of a 2-year-old girl is asking her friend when she should start potty training the child. The mother expresses concern about the high cost of diapers and training pants and would really like to have her trained as soon as possible. Which advice by the friend would be considered the best response?

"When she is uncomfortable in her wet diaper and brings a clean diaper to you, that's a good indication she is ready for potty training." explanation: The markers of readiness are subtle, but as a rule, children are ready for toilet training when they begin to be uncomfortable in wet diapers. They demonstrate this by pulling or tugging at soiled diapers, or they may bring a parent a clean diaper after they have soiled so they can be changed. The other answers do not address this. Usually the child needs to walk well independently before training can occur.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel?

Antidiarrheal agent explanation: Antidiarrheal agents act directly on the intestine to slow bowel motility or to absorb excess fluid in the bowel. Antiflatulence agents are used to relieve gas. Laxatives promote evacuation of hardened stool from the bowel. Suppositories, when inserted into the rectum, melt and can be absorbed for systemic or local effects.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. explanation: The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.

The nurse is caring for a client who has a history of renal failure. What is an accurate step when caring for the client's hemodialysis access?

Auscultate over the site with a stethoscope to listen for a bruit. explanation: The nurse should auscultate over the access site with the bell of the stethoscope, listening for a bruit or vibration, and palpate over the access site, feeling for a thrill or vibration. If these are not present, the health care provider should be notified at once. An IV should not be started in the arm with the access.

The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next?

Blood sugar explanation: Glycosuria is a condition that describes the finding of glucose in the urine. The natural next step would be to obtain a fingerstick for blood glucose level. Vital signs are a baseline indicator of any illness or injury. Intake and output may be important going forward, but the diagnosis directs the next action.

Which symptom is a known side effect of antibiotics?

Diarrhea explanation: A side effect of taking antibiotics is diarrhea. Constipation, fecal impaction, and abdominal bloating are not common side effects of antibiotics.

A female infant has voided for the first time. The nurse notes the urine is light pink tinged. What actions by the nurse are indicated?

Document the findings as normal, recognizing that they have been caused by an accumulation of uric acid crystals. explanation: The first voiding may be of slightly pink-tinged urine, caused by an accumulation of uric acid crystals.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. explanation: Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first?

Stop the administration of the enema momentarily. explanation: If the client reports abdominal discomfort or cramping, the nurse should momentarily stop the flow of solution. Increasing the flow of the enema may cause more cramping and discomfort. Cramping and discomfort are common complaints during enema administration so there is no need to notify the physician.

A 5-year-old client has a gastrointestinal infection. His mother plans to send him to school tomorrow. The school nurse knows that which nursing outcome is most important to include in the care plan of the client?

The client will demonstrate good health practices to prevent spread of infection. explanation: Children should not, but may, return to a school or daycare setting during the infectious phase of their illness. Hand washing is key to preventing the spread of infection. There is no need for the client to tell others they are ill. Isolation from others at school is not an effective strategy for the client.

A client's recent diagnosis of colorectal cancer has required a hemicolectomy (removal of part of the bowel) and the creation of a colostomy. The nurse would recognize that the client's stoma is healthy when it appears what color?

dark pink and moist explanation: A healthy stoma is dark pink to red and moist. Redness, as well as moisture, is normal to the stoma. Pallor may suggest anemia and a dark appearance may indicate

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?

dehydration explanation: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The symptoms are not associated with hypovolemia, balanced fluids, nor renal failure.

A 57-year-old man is suffering from polyuria. What can cause polyuria?

diabetes insipidus explanation: Untreated diabetes insipidus can cause an increase in the formation and excretion of urine without a concurrent increase in fluid intake. Renal disease often leads to oliguria and even anuria, a decrease in urine outputs. Urinary tract infections cause an increase in frequency but not necessarily an increase in the amount of urine that is produced. Renal calculi can cause hematuria.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination explanation: There is a specific sequence that bowel tests must be performed due to the results of certain contrasts and other preps that must be given. The nurse would verify that the tests are done in the correct order: Fecal occult blood test, barium studies, and then endoscopic examination.