Unit 11 elimination
after a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 ml/hr. The nurse empties the drainage bag for a total of 2520 ml after an 8 hour period. How much of the total is urine output?
1320
The student instills a total of 60 ml of the correct solution and withdraws 40 ml of fluid containing several small blood clots. The student then empties 200 ml from the urinary drainage bag. What output should be recorded
180
A female patient reports that she is experiencing burning on urination, frequency and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: A) cystitis B) hematuria C) pyelonephritis D) dysuria
A
A patient is admitted for lower GI bleeding. What color stool does the nurse anticipate the patient to have? A) red B) black C) green D) orange
A
Before collecting a stool sample for occult blood, the nurse instructs the NA personnel to: A) ask the patient to void B) wash the patients perineum C) secure a sterile specimen container D) plan to collect the first specimen of the day
A
Clyde has preoperative prescriptions that include insertion of an indwelling catheter. The SN is assigned to care for him, and obtains a catherter insertion tray that includes 22 Foley catheter with a 5 ml balloon. The student preceptor will supervise the student. What action should the nurse take? A) suggest the use of a smaller diameter catheter B) recommend the use of a straight rubber catheter C) advise the student to use a larger balloon D) affirm that the student has the correct Equiptment
A
Following an incontient episode the nurse observes that the NA washes the clients perineal area with mild soap and water and applies water repellant ointment to the skin exposed to urine What action should the nurse implement A) comment the NA for the good care being provided to the client B) advice the NA to avoid the use of any soap around the perineal area C) instruct the NA that the application of lotions and ointments increases the risk of skin breakdown D) suggest that the NA continue with the current actions and also massage any reddened areas
A
Since removal of the patients Foley catheter, the patient has voided 50 to 100 ml every 2 to 3 hours. Which action should the nurse take first? A) check the bladder for distention B) encourage fluid intake C) obtain an order to recatheterize the patient D) document the amount of each voiding for 24 hours
A
The nurse anticipates that the prescription will include the use of which of the sterile solution to irrigate the catheter A) normal saline B) hydrogen peroxide C) heparinized saline solution D) chlorhexidine antiicrobial solution
A
The nurse encourages the NS to perform the irrigation. The student prepares the solution, applies gloves, clamps the distal tubing, and begins to clean the specimen port on the drainage tubing. What action should the nurse take? A) encourage the student to continue, maintaining aseptic technique B) instruct the student to instill 30 ml of air, followed by 30 ml of solution C) advise the student to leave the distal clamp in place for 30 minutes D) remind the student to empty the drainage bag before instilling the solution
A
The nurse reviews factors that may impact catheter insertion. Which physiological change that commonly occurs in elderly males may affect insertion of the catheter A) prostate gland enlargement B) urethral stricture C) diminished bladder capacity D) weakened detrusor muscle
A
a male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be most beneficial in assisting the patient to void? A) suggest he stand at the bedside table B) stay wit the patient C) give him the urinal to use in bed D) tell him that if he doesn't urinate he will be catheterized
A
after obtaining a prescription for wrist restraints the nurse applies the restraints and plans to monitor the pt every 30 minutes which assessment is most important for the nurse to perform at each of these times? A) skin integrity and pulse volume of the restrained extremities B) ausculation of bilateral breath sounds and heart C) vs and o2 saturation via pulse oximetry D) the presence and integrity of invasive tubing
A
since clydes creatinine level is elevated, the nurse is concerned about which problem in administering the medication? A) drug toxicity due to reduced drug excretion B) decreased effectiveness due to poor absorption C) altered first pass effect due to reduced liver function D) increased free drug molecules due to low albumin levels
A
Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (select all that apply) A) incontinence B) frequency C) urgency D) urinary retention E) UTI
A, B, C, D, E
A patient with a Foley catheter carries the collection bag at waist level when amulating. The nurse tells the patient that he or she is at risk for (select all that apply) A) infection B) retention C) stagnant urine D) reflex of urine
A, D
The nursing staff continues with the bladder training program, but Clyde's incontinence shows little improvement. Since the bladder training has not been sucessful, the nurse obtains a prescription to apply a condom catheter. Clyde is ambulatory with assistance which technique should be used when applying the condom catheter A) clean and dry the penis before applying the condom catheter B) secure the condom with adhesive tape to prevent dislodgment while ambulating C) ensure that the condom fits snugly over the tip of the glans penis D) return the foreskin to its normal positon after applying skin prep to the penis shaft E) attach a large leg drainage bag to reduce the frequency of bag emptying while ambulating
A, D
which of the following medications listed in a patients medication history possibly causes gastrointestinal bleeding? (Select all that apply) A) asprin B) cathartics C) antidiarrheal opiate agents D) nonsteroidal antiinflammatory drugs (NSAID's)
A, D
The patient is to have an IVP (intravenous pyelogram.) Which of the following apply to this procedure (select all that apply) A) note any allergies B) monitor intake and output C) provider perineal hygiene D) assess vs E) encourage fluids after the procedure
A, E
The catheter is successfully placed in the bladder with a return of 200 ml of clear, yellow urine. The catheter is secured, and clyde is resting comfortably. In documenting the catheter insertion procedure, which statement should be included A) no prostate gland enlargement noted during catheter insertion B) 16 Foley catheter inserted with return of clear, yellow urine C) 5 ml balloon inflated in the urethra but client is now comfortable D) indwelling catheter inserted because the client is incontinent
B
The nurse is caring for a 78 year old man with diarrhea. Of the following problems, which is the most important to consider A) malnutrition B) dehydration C) skin breakdown D) incontinence
B
The nurse notes that the patients Foley catheter bag has been empty for 4 hours. The priority action would be to A) irrigate the foley B) check for kinks in the tubing C) notify the HCP D) assess the patients intake
B
To encourage voiding the nurse instructs the NA to perform what intervention? A) apply firm pressure to the bladder for 2-3 minutes B) turn on the tap water so it is running when the client attempts to void C) place the clients hands in a basin of ice cold water D) place the client in a left lateral sims position
B
since clyde voids spontaneously without recognizing the need to void, how should the nurse describe his current urinary pattern? A) polyuria B) incontinence C) retention D) Oliguria
B
what technique will the nurse use to mix clyde's medication with his food. A) crush the capsule and mix with applesauce B) open the capsule and mix the medication with pudding C) dissolve the capsule in a glass of warm milk D) open the capsule and mix it in a glass of fruit juice
B
which diagnostic test result identifies the client as being at risk for sepsis? A) serum creatine and BUN are both elevated above normal B) urine culture shows resistance to prescribed antibiotics C) partial thromboplastin time (PTT) is excessively prolonged D) CBC shows low hemoglobin and hematocrit levels
B
list the correct order in which to apply an ostomy pouch A) remove the used pouch and skin barrier B) perform hand hygiene and apply clean gloves C) assess the stoma for color, swelling and healing D) gently cleanse the peristomal skin with warm tap water E) apply nonallergenic tape around the pectin skin barrier F) cut an opening on the pouch larger than the stoma G) press the adhesive backing of the pouch smoothly against the skin
B, A, D, C, F, G, E
During the catheter irrigation the nurse observes that clyde is still confused and attempts to pull at his catheter, his IV and his nasal cannula The nurse considers the use of wrist restraints based on what rationale? A) the client is confused B) the client just had surgery C) the client is at risk for self injury D) There is no family member to stay with the client
C
During the nursing assessment a patient reveals that he has dirrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with A) food allergy B) irritable bowel C) lactose intolerance D) increased peristalsis
C
Prior to his stroke, clyde often awakened 5 or 6 times during the night to void but was able to control urge long enough to make it to the bathroom How should the nurse describe the pre-stroke urinary pattern? A) dysuria B) frequency C) noturia D) diuresis
C
The nurse understands that when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed for A) minimize the risk of bowel obstruction B)ensure drainage of the intestines C) prevent gastric mucosal damage D) promote resting the gut
C
The patient states that she loses urine every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states A) "i will perform my kegel exercises every day" B) "I joined weight watchers" C) "I drink two glasses of wine with dinner" D) "I have tried urinating every 3 hours"
C
clyde is experiencing incontinence and often wets his clothing even with toileting every two hours. The nurse enters clydes room to find him crying what is the best initial response by the nurse to this behavior? A) leave clyde alone until his crying subsides B) assign a NA to sit with clyde C) acknowledge to clyde the distress that he is experiencing D) provide a distracton, such as turning on the television
C
clyde returns from PACU. He is confused and frequently pulls on the urinary catheter. The nurse observes hematuria in the drainage bag and notes the presence of several blood clots in tubing which recording objectively documents the situation A)client does not know what he is doing, and he has caused bleeding to occur in the urine B) surgery caused clients confusion, resulting in pulling on the catheter and hemorrhage C) client is confused and pulls on Foley catheter. Urine is pink-red with blood clots D) the client was instructed to not pull on his catheter, and now there is hematuria in the tubing
C
clyde voids 4 hours after the catheter is removed. He is discharged to the long term care facility. Clydes medication has been switched to oral but clyde has some difficulty swallowing. The nurse is considering the best technique to help clyde swallow his mediction. Before deciding to open the capsule and mix it with food, what will the nurse determine? A) is the capsule scored for ease of opening? B) was clyde able to swallow the capsules prior to his stroke C) is the medication in extended release form? D) does the medication come in a unit dose package
C
clyde's indwelling catheter is removed by the nurse on the morning of clyde's anticipated discharge. The nurse instructs the NA to report if clyde has not voided within what period of time? A) 2 hours B) 4 hours C) 8 hours D) 12 hours
C
patients urine develops a cloudy appearance. which action should the nurse implement A) assess the clients skin tugor B) continue catheter irrigations C) obtain a sterile urine specimen D) palpate for bladder distention
C
the nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patinet to A) use the double-voiding technique B) perform kegel exercises C) use credes method D) keep a voiding diary
C
the nurse directs the NA to remove a Foley catheter at 1300. The nurse would check if the patient has voided by: A) 1400 B) 1600 C) 1700 D) 2300
C
the nurse is caring for a patient with a colonostomy. Which intervention is most important A) cleaning the stoma with hot water B) inserting a deodorant tablet in the stoma bag C) selecting a bag with an appropriate size stoma opening D) wearing sterile gloves while caring for the stoma
C
the nurse is taking a HH of a newly admitted patient with a diagnosis. Rule out bowel obstruction. Which of the following is the priority question to ask the patient? A) describe your BM B) how often do you have a BM C) when was the last time you moved your bowels? D) do you routinely use stool softeners, laxatives, or enemas?
C
the patient is incontinent and a condom catheter is placed. The nurse should take which action? A) secure the condom with adhesive tape B) change the condom every 48 hours C) assess the patient for skin irritation D) use sterile technique for placement
C
when assessing a 55 year old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing A)if patient reports rectal bleeding B) when there is a family history of polyps C) as part of a routine examination for colon cancer D) if a palpable mass is detected on digital examination
C
Nurses discourage patients from straining on defecation primarily because it causes (select all that apply) A) pain B) impaction C) hemorrhoids D) dysrhythmias
C, D
A cleansing enema is ordered for a 55 year old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is A) 150-200 ml B) 200-400 ml C) 400-750 ml D) 750-1000 ml
D
A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first? A) administers pain medication B) slows down the rate of instillation C) tells the patient to breathe slowly and relax D) stops the instillation and obtains vs
D
Clydes bladder training program is unsuccessful and he continues to be incontinent. When establishing clydes plan of care the nurse includes which diagnosis A) fluid volume deficit related to voiding patterns B) fluid volume excess related to altered urination C) Risk for uremic syndrome related to unresolved incontinence D) risk for impaired skin integrity related to urinary incontinence
D
Clydes hematuria continues. Two hors later, he becomes restless and appears to be in pain. The nurse observes that there has been no urinary output in the last 2 hours. What assessment should the nurse complete first A) palpate for bladder distention B) obtain BP C) Measure 02 saturtaion D) observe the urinary drainage tubing
D
The NA is changing clyde's clothes. The nurse stops in to assess the situation. Which aspect of the situation requires the nurses most immediate intervention? A) the room temperature is excessively warm B) a soap opera is playing loudly on the television C) A second NA is watching television rather than helping D) clydes room door is open to the hallway
D
The nurse notes that the medication dosage is in the safe range for elderly clients. The medication is to be administered by IV every 12 hours the nurse recognizes that the frequency of drug administration is based on which characteristic of the medication? A) bioavailability B) protein binding C) therapeutic index D) half-life
D
The student obtains a 16 Foley catheter from the supply room. She explains the procedure to clyde, who gives her permission to begin. After cleansing the urinary meatus, the SN maintains sterile technique while inserting the catheter into the urethra about 4 inches and inflating the balloon. Clyde cries out in obvious pain. The nurse should advise the student to take what action A) reassure the client that the pain he is experiencing is only temporary B) tape the catheter to the clients abdomen to prevent further movement C) remove the catheter from the urethra immediately D) deflate the balloon, and insert the catheter farther
D
To minimize the patient experiencing nocturia, the nurse would teach him or her to A) perform perineal hygiene after urinating B) set up a toileting schedule C) double void D) limit fluids before bedtime
D
after 24 hours of recieving antibiotics clydes condition has not improved. Urinalysis results are: Ph 8.5 Specific gravity 1.015 protein : none glucose: none WBC: 8 RBC: 2 bacteria present based on urinalysis results the HCP prescribes broad spectrum antibiotic. What additional nursing intervention will the nurse implement? A) encourage the intake of high-protein foods B)offer additional high-carbohydrate snacks C) reduce the clients water intake D) provide a glass of cranberry juice daily
D
an older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to A) help him stand to void B) place a condom catheter C) have him practice credes method D) initial kegal exercise
D
nurse initiates a bladder training program for clyde. which instruction should the nurse provide the NA who is helping care for clyde? A) restrict oral fluids to 1,000 ml daily in evenly divided amounts B) offer warm coffee, cocoa or tea every 2 hours while awake C) limit client socialization until voiding patterns are established D) remind the patient to void every 2 hours while awake
D
the nurse recognizes which patient needs to use a fracture pan for a BM? A) the patient who is obese B) the patent experiencing confusion C) the patient on bed rest D) a patient recovering from hip surgery
D
the postoperative patient has difficulty voiding after surgery and is feeling uncomfortable in the lower abdomen. Which action should the nurse implement first? A) encourage fluid intake B) administer pain medication C) catheterize the patient D) turn on the bathroom faucet as he tries to void
D
number the steps to irrigating a NG tube in correct order A) slowly aspirate the syringe B) reconnect the NG tube to suction C) clamp and disconnect the NG tube D) perform hand hygiene and apply clean gloves E) insert tip of syringe into NG tube and slowly inject 30 ml saline
D, C, E, A, B
a cloudy urine appearance may be an indicator of ..?
UTI