Elimination

An emergency department nurse assesses an older client who reports cramping pain in the left lower quadrant, weakness, bloating, and malaise. The client also has a low-grade fever. Which condition does the nurse suspect as the most likely cause of the client's clinical findings?

Diverticulitis

A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the health care provider. What should the nurse do to help prevent the client from developing a urinary tract infection?

Maintain the prescribed hydration

The nurse is caring for a client that weighs 90 kilograms. The nurse is determining the client's response to fluid replacement therapy. The clinical finding that indicates adequate tissue perfusion to vital organs is:

Urinary output of 60 mL/hr

A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the surgeon?

Urine output of 20 mL/hour

After surgery to create an ileal conduit, a client is admitted to the postanesthesia care unit. Which clinical finding during the first hour of the postoperative period should the nurse report to the health care provider?

Absence of urinary output

The nurse concludes that a client who had a transurethral vaporization of the prostate understands the discharge teaching when the client says, "I should:

Notify my primary health care provider if my urinary stream decreases."

An infant with diarrhea requires contact precautions. What is the most effective nursing action to control the spread of this infant's pathogens?

Washing hands before and after contact with the infant

A client has a permanent colostomy. During the first 24 hours there is no drainage from the colostomy. The nurse concludes that this is a result of the:

Absence of intestinal peristalsis.

What does the nurse anticipate that a primipara with a second-degree laceration and repair is most likely to experience during the postpartum period?

Difficulty voiding spontaneously

What is the priority intervention for a client during the early postoperative period after a prostatectomy?

Discourage straining for a bowel movement

Trimethoprim-sulfamethoxazole (Septra) is prescribed for a client with cystitis. When teaching about the medication, the nurse instructs the client to:

Drink 8 to 10 glasses of water daily

A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. What should the nurse include in the home care instructions?

Drink at least 3 L of fluid daily for four weeks

A nurse is caring for a client who just had a gastrectomy. What should the nurse emphasize when teaching the client how to avoid dumping syndrome?

Eat small meals with low carbohydrate and moderate fat content

A nurse admits a client with a diagnosis of cholelithiasis for surgery. The client asks many questions about the postoperative course after laparoscopic surgery. What is most important for the nurse to include in the teaching plan?

Explanation of abdominal and scapular pain

What liquid should a nurse recommend that a mother offer her 8-month-old infant who has diarrhea?

Formula

After surgery to create an ileal conduit, a client awakens and asks for a sip of water. The nurse informs the client that water by mouth cannot be given until the:

Nasogastric suction is discontinued.

An infant is admitted to the pediatric unit for surgery to correct hypertrophic pyloric stenosis (HPS). What clinical finding should the nurse anticipate when performing a physical assessment of the infant's abdomen?

Olive-sized mass in the right upper quadrant

The nurse identifies a decrease in serum sodium when reviewing the laboratory reports of an older client with diarrhea. A decrease in which additional electrolyte is a cause for the greatest concern for this client?

Potassium

A nurse is caring for a client with a new colostomy. Which client outcome is most important for achievement of long-range goals associated with adjusting to a new colostomy?

Readiness to accept an altered body function

One week after beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. The client is admitted with a diagnosis of thyrotoxic crisis. The nurse determines that the most important intervention for this client is:

Reducing body temperature and heart rate

A nurse is caring for a client with diarrhea. The nurse anticipates a decrease in which clinical indicator?

Tissue turgor

A client had a colostomy surgery and is learning how to care for the skin around the stoma. What should the nurse include in the teaching plan for this client?

Wash the area gently with soap and water before applying an appliance

A client is admitted to the hospital with severe flank pain, nausea, and hematuria caused by a ureteral calculus. A lithotripsy is scheduled. What is the priority nursing action when caring for this client?

Administer the prescribed analgesic.

To facilitate micturition in a male client, the nurse should instruct him to:

Assume the standing position for voiding

A primary health care provider prescribes three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound weight loss in one month. To ensure valid test results, the nurse should instruct the client to:

Avoid eating red meat before testing

An infant with a cardiac defect is fed in the semi-Fowler position. After the nurse feeds and burps the infant and changes the infant's position, the infant has a bowel movement and almost immediately becomes cyanotic, diaphoretic, and limp. Which activity most likely caused the infant's response?

Bowel movement

A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client?

Check the client's buttocks at least every two hours; clean the patient immediately after discovering incontinence.

A nurse who has agreed to serve as camp nurse for a week has an influx of children with abdominal pain late in the week. The nurse encourages the camp cook to increase the amounts of fruits and vegetables, whole grains, and other high-fiber foods in the meals. The nurse knows that this will help decrease the incidence of abdominal pain caused by:

Constipation

A client will be taking nitrofurantoin (Macrobid) 50 mg orally every evening at home to manage recurrent urinary tract infections. What instructions should the nurse give to the client?

Increase the intake of fluids

A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse identify as the greatest risk for this infant?

Infection

A nurse is discussing the regaining of bowel control with a client who recently had surgery for a colostomy in the descending colon. What is most important to emphasize in this teaching?

Irrigation routine

A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence?

Institute measures to prevent constipation

As the nurse is conducting the discharge assessment, the 2-day-old neonate expels a large amount of meconium. What does the nurse conclude about this occurrence?

It is a common finding in 2-day-old neonate.

A physician prescribes a Schilling Test for a client. Which measure would the nurse take to ensure the prescription is carried out?

Start a 24 to 48 hour urine specimen collection.

An infant is born with exstrophy of the bladder. What instruction by the health care provider does the nurse expect to protect the exposed bladder until surgery is performed?

Sterile nonadherent dressings

A nurse is caring for a client with continuous bladder irrigation. Which is the most important nursing action?

Subtracting irrigant from output to determine urine volume.