Elimination Concept

13. What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding. 2. Catheterize the patient 30 minutes after voiding. 3. Bladder scan the patient when he or she reports a strong urge to void. 4. Catheterize the patient with a 16 Fr/10 mL catheter.

1

2. A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what do you suspect is wrong with the patient? 1. An intestinal obstruction 2. Irritation of the intestinal mucosa 3. Gastroenteritis 4. A fecal impaction

1

3. During the administration of a warm tap-water enema, a patient complains of cramping abdominal pain that he rates 6 out of 10. What is your priority nursing intervention? 1. Stop the instillation 2. Ask the patient to take deep breaths to decrease the pain 3. Add soapsuds to the enema 4. Tell the patient to bear down as he would when having a bowel movement

1

5. Which skills do you teach a patient with a new colostomy before discharge from the hospital? (Select all that apply.) 1. How to change the pouch 2. How to empty the pouch 3. How to open and close the pouch 4. How to irrigate the colostomy 5. How to determine if the ostomy is healing appropriately

1,2,3,5

8. Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) 1. Change in bowel habits 2. Blood in the stool 3. A larger-than-normal bowel movement 4. Fecal impaction 5. Muscle aches 6. Incomplete emptying of the colon 7. Food particles in the stool 8. Unexplained abdominal or back pain

1,2,6,8

8. What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily.

1,3,4

1. A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract.

1,4

4. Which instructions do you include when educating a person with chronic constipation? (Select all that apply.) 1. Increase fiber and fluids in the diet 2. Use a low-volume enema daily 3. Avoid gluten in the diet 4. Take laxatives twice a day 5. Exercise for 30 minutes every day 6. Schedule time to use the toilet at the same time every day 7. Take probiotics 5 times a week

1,5,6

1. Which of the following nursing actions do you take after placing a bedpan under an immobilized patient? 1. Lift the patient's hips off the bed and slide the bedpan under the patient 2. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle 3. Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient 4. Have the patient stand beside the bed and then have him or her sit on the bedpan on the edge of the bed

2

11. The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? 1. Implement the "as-needed" order to irrigate the catheter 2. Assess the catheter and drainage tubing for obvious occlusion 3. Notify the health care provider immediately 4. Assess the vital signs and intake and output record

2

14. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water

2

15. An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? 1. Malnutrition 2. Dehydration 3. Skin breakdown 4. Incontinence

2

15. There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter 2. Leave the catheter there and start over with a new catheter 3. Pull the catheter back and reinsert at a different angle 4. Ask the patient to bear down and insert the catheter further

2

6. A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI 2. Assess the intake and output from system 3. Decrease the rate of the CBI 4. Assess vital signs

2

7. An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication 2. Start a scheduled toileting program 3. Recommend that she be evaluated for an indwelling catheter 4. Start a bladder-retraining program

2

12. Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal

2,3

6. Which of the following cause Clostridium difficile infection? (Select all that apply.) 1. Chronic laxative use 2. Contact with C. difficile bacteria 3. Overuse of antibiotics 4. Frequent episodes of diarrhea caused by food intolerance 5. Inflammation of the bowel

2,3

10. What do you need to teach family caregivers when a patient has fecal incontinence as a result of cognitive impairment? 1. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks 2. Use diapers and heavy padding on the bed 3. Initiate bowel or habit training program to promote continence 4. Help the patient to toilet once every hour

3

13. Which nursing intervention is most important when caring for a patient with an ileostomy? 1. Cleansing the stoma with hot water 2. Inserting a deodorant tablet in the stoma bag 3. Selecting or cutting a pouch with an appropriate-size stoma opening 4. Wearing sterile gloves while caring for the stoma

3

14. A nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? 1. Have you eaten more high-fiber foods lately? 2. Are your bowel movements soft and formed? 3. Have you experienced frequent, small liquid stools recently? 4. Have you taken antibiotics recently?

3

2. When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine 2. Slightly cloudy urine 3. Light pink urine 4. Dark amber urine

3

3. What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bed sheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert ¼ inch more.

3

4. Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube 2. Shaving the pubic area so hair does not adhere 3. Washing with soap and water before applying the condom-type catheter 4. Applying tape to the condom sheath to keep it securely in place

3

5. Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan.

3

9. A nurse is teaching a patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? 1. Get three fecal smears from one bowel movement. 2. Obtain one fecal smear from an early-morning bowel movement. 3. Collect one fecal smear from three separate bowel movements. 4. Get three fecal smears when you see blood in your bowel movement.

3

9. Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine?

3

11. Your patient states, "I have diarrhea and cramping every time I have ice cream. I am sure this is because the food is cold." Based on this assessment data, which health problem do you suspect the patient has? 1. A food allergy 2. Irritable bowel syndrome 3. Increased peristalsis 4. Lactose intolerance

4

10. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus with antiseptic solution. 5. Drape patient with the sterile square and fenestrated drapes. 6. When urine appears, advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing.

5,7,2,4,1,6,3,8,9

7. Place the steps for an ostomy pouch change in the correct order. 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin.

5,8,7,2,6,3,4,1

12. Place the steps to administering a prepackaged enema the correct order. 1. Insert enema tip gently in the rectum. 2. Help patient to bathroom when he or she feels urge to defecate. 3. Position patient on side. 4. Perform hand hygiene and apply clean gloves. 5. Squeeze contents of container into rectum. 6. Explain procedure to the patient.

6,4,3,1,5,2

2. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take? a. Check to see whether the catheter is patent b. Reassure the client that it is not possible for her to urinate. c. Recatheterize the bladder with a larger-gauge catheter d. Collect a urine specimen for analysis

a

3. The nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take? a. Discard the first voiding b. Keep the urine in a single container at room temperature c. Ask the client to urinate and pour the urine into a specimen container d. Ask the client to urinate into the toiler, stop midstream, and finish urinating into the specimen container

a

5. A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (select all that apply) a. Warm the enema solution prior to instillation. b. Position the client on the left side with the right leg flexed forward. c. Lubricate the rectal tube or nozzle d. Slowly insert the rectal tube about 5 cm (2in). e. Hang the enema container 61 cm (24 in) above the client's anus)

a,b,c

4. A nurse is reviewing factors that increase the risk of urinary tract infections with a client who has recurrent UTIs. Which of the following factors should the nurse include? (select all that apply) a. Frequent sexual intercourse b. Lowering of testosterone levels c. Wiping from front to back d. Location of the urethra in relation to the anus e. Frequent catheterization

a,d,e

2. A nurse is talking with a client who reports constipation. When the nurse discusses dietary changes that can help prevent constipation, which of the following foods should the nurse recommend? a. Macaroni and cheese b. Fresh fruit and whole wheat toast c. Bread pudding and yogurt d. Roast chicken and white rice

b

3. A nurse is caring for a client who has had diarrhea for 4 days. When assessing the client, the nurse should expect which of the following findings? (select all that apply) a. Bradycardia b. Hypotension c. Elevated temperature d. Poor skin turgor e. Peripheral edema

b, c, d

5. A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (select all that apply.) a. Establish a schedule of urination prior to meal times b. Have a client record urination times c. Gradually increase the urination intervals d. Remind the client to hold urine until the next scheduled urination time e. Provide a sterile container for urine

b,c,d

1. A nurse in a provider's office is evaluation a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence. a. Limit total daily fluid intake. b. Decrease or avoid caffeine c. Take calcium supplements d. Avoid drinking alcohol e. Use the Crede maneuver.

b,d

1. A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client? a. Eating more protein is optimal prior to testing b. One stool specimen is sufficient for testing c. A red color change indicates a positive test d. The specimen cannot be contaminated with urine.

d

4. While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take? a. Have the client hold his breath briefly and bear down b. Discontinue the fluid instillation c. Remind the client that cramping is common at this time d. Lower the enema fluid container

d