Fundamentals Quiz 4

4 (The client's normal bowel elimination pattern)

A client asks the nurse to take a laxative, as he or she has not had a bowel movement today. What is the first information the nurse should obtain prior to administering the laxative? 1. The amount of fiber in daily diet 2. The last dose of laxative received 3. If the client has had any flatus 4. The client's normal bowel elimination pattern

2, 3, 5, 6 (popcorn, dried beans, raw vegetables, whole-grain breads)

A client asks the nurse which foods would help to consume 25 to 30 grams of fiber per day. Which foods should the nurse instruct the client to include in the diet? Select all that apply. 1. Pasta 2. Popcorn 3. Dried beans 4. Applesauce 5. Raw vegetables 6. Whole-grain breads

4 (the client should increase fiber intake)

A client has a tendency to develop frequent constipation. Which dietary consideration should the nurse recommend? 1. The client should increase iron intake. 2. The client should decrease fiber intake. 3. The client should increase intake of fats. 4. The client should increase fiber intake.

1 (an increase in specific gravity)

A client has been having severe diarrhea and fever for the past few days with decreased urinary output. Which would be the expected effect on the urine specific gravity? 1. An increase in specific gravity 2. A decrease in specific gravity 3. No change in specific gravity of urine 4. Unable to determine with the information provided

3 (dehydration)

A client presents to the emergency department with nausea and vomiting for 2 days. The client states he or she has not urinated at all for the past 8 hours. Which is the most likely cause of his lack of urine output? 1. Impaired renal function 2. Renal calculi 3. Dehydration 4. Prostatic hypertrophy

2, 4 (chronic constipation, prolonged sitting on the job)

A client presents to the emergency room passing bright red blood from the rectum. The health-care provider determines the client has bleeding hemorrhoids. Which causative factors should the nurse ask the client about? Select all that apply. 1. Anorexia nervosa 2. Chronic constipation 3. End stage renal disease 4. Prolonged sitting on the job 5. Upper gastrointestinal bleeding

4 (antidiuretic hormone- ADH)

A client presents to the emergency room with vomiting and diarrhea. The client is dehydrated. Which hormone does the nurse expect to be secreted by the posterior pituitary gland to reduce water loss? 1. Renin 2. Aldosterone 3. Erythropoietin 4. Antidiuretic hormone (ADH)

2, 4, 5 (beans, onions, broccoli)

A client with irritable bowel syndrome reports excess gas after meals. Which foods should the nurse instruct the client to avoid in the diet to decrease gas production? Select All That Apply. 1. Pasta 2. Beans 3. Yogurt 4. Onions 5. Broccoli

3 (constipation)

A nurse is auscultating bowel sounds on a client who has had recent abdominal surgery. She hears approximately 1 to 2 sounds per minute in each quadrant. Which condition should the nurse expect? 1. Infection 2. Diarrhea 3. Constipation 4. Ileus

4 (Metformin)

A nurse is caring for a client with type 2 diabetes mellitus who is scheduled to undergo a computed tomography (CT) scan with IV contrast of the abdomen due to suspected intestinal malignancy. Which medication should the nurse hold prior to the procedure and for 48 hours after the procedure? 1. Insulin 2. Diazepam 3. Bisacodyl 4. Metformin

2 (check on the client every 2 hours and offer toileting assistance)

A nurse is caring for an elderly client who has nearly fallen twice while getting out of bed to go to the bathroom. The nurse has instructed the client not to get up without assistance. The client tells the nurse about feeling a need to get to the bathroom when the urge to void occurs and feeling a need to rush. Which strategy should the nurse utilize to minimize the client's risk of falling? 1. Obtain an order for an indwelling catheter. 2. Check on the client every 2 hours and offer toileting assistance. 3. Require that a family member stay with the client. 4. Obtain an order for restraints to prevent injury.

3 (deflate the balloon and advance the catheter about an inch before attempting again)

A nurse is inserting an indwelling catheter into a client. She begins to inflate the balloon, she feels resistance, and the client complains of discomfort. Which action should the nurse take? 1. Remove the catheter and discard it. 2. Notify the physician and document that the client refused a catheter. 3. Deflate the balloon and advance the catheter about an inch before attempting again. 4. Leave the catheter in place without inflating the balloon.

2 (the client takes iron supplements)

A nurse is performing a health history interview. The client has a complaint of chronic constipation. Which piece of information is most helpful to the nurse in determining contributing factors to the constipation? 1. The client has recently been on antibiotics. 2. The client takes iron supplements. 3. The client tires easily and does not exercise much. 4. The client has been having trouble sleeping.

4 (decreased heart rate)

During digital removal of stool, which is the most serious complication the client is at risk of developing? 1. Bleeding 2. Decreased blood pressure 3. Hypertension 4. Decreased heart rate

4 (3 minutes)

How long should the nurse auscultate each quadrant prior to documenting the absence of bowel sounds? 1. 30 seconds 2. 1 minute 3. 2 minutes 4. 3 minutes

3 (Percuss between the 12th rib and spine)

How would the nurse assess for costovertebral angle tenderness? 1. Inspect the urinary meatus. 2. Auscultate over the abdominal aorta. 3. Percuss between the 12th rib and spine. 4. Palpate in the pubic area over the bladder.

1, 3, 4, 5 (anesthesia, stress, decreased mobility, manipulation of the bowel)

In which ways can surgery or procedures contribute to sluggish bowel elimination? Select all that apply. 1. Anesthesia 2. Increased IV fluids 3. Stress 4. Decreased mobility 5. Manipulation of the bowel

3 (assess the urine color and clarity)

The nurse calculates urinary output for a client admitted with dehydration and determines the client's output is 800 mL/day. Which nursing intervention is most appropriate for the nurse to perform first? 1. Notify the health-care provider. 2. Document the finding as normal. 3. Assess the urine color and clarity. 4. Insert an indwelling urinary catheters

4 (clamping the tubing and withdrawing a fresh specimen from the tubing aseptically)

The nurse has an order to obtain a urine specimen for a culture and sensitivity test from a client with an indwelling urinary catheter. Which procedure is accurate for obtaining the specimen? 1. Obtaining the specimen from the drainage bag 2. Disconnecting the tubing and obtaining the specimen 3. Inserting a new indwelling urinary catheter to obtain a sterile urine specimen 4. Clamping the tubing and withdrawing a fresh specimen from the tubing aseptically

1 (determine if the gag reflex has returned)

The nurse is caring for a client in the endoscopy recovery area after undergoing an esophagogastroduodenoscopy (EGD). The client asks for a sip of water. What should the nurse do first? 1. Determine if the gag reflex has returned. 2. Telephone the gastroenterologist for orders. 3. Review the electronic health record (EHR). 4. Inform the client that he or she is still NPO for 12 to 24 hours.

4 (Take stool softeners to prevent straining.)

The nurse is caring for a client who is being discharged after sustaining a myocardial infarction. What is most important for the nurse to instruct the client? 1. Consume a bland diet. 2. Use a salt substitute on foods. 3. Avoid consuming grapefruits and its juice. 4. Take stool softeners to prevent straining.

1 ("The tube is in place to remove secretions until the bowels begin to work.")

The nurse is caring for a client who underwent bowel surgery and returns to the floor with a nasogastric tube to low intermittent wall suction. The family questions the nurse as to why the client has the tube. What is the nurse's best response? 1. "The tube is in place to remove secretions until the bowels begin to work." 2. "The tube is in place in order for us to administer medications." 3. "The tube is in place to administer tube feedings until the bowel heals." 4. "The tube is in place to assess for gastrointestinal bleeding postoperatively."

4 (intravenous pyelogram)

The nurse is caring for a client with acute kidney injury and reviews the medical record for new orders. Which order given by the health-care provider should the nurse question? 1. Cystoscopy 2. Cystometry 3. Renal biopsy 4. Intravenous pyelogram

2,3,6 (rice, toast, applesauce)

The nurse is caring for a client with diarrhea related to a virus. According to the BRAT diet, which foods should the nurse instruct the client to include in the diet? Select all that apply. 1. Tea 2. Rice 3. Toast 4. Raisins 5. Asparagus 6. Applesauce

1, 2, 3, 4 (diminished mobility, lowered fluid intake, decreased peristalsis, changes in fiber intake)

The nurse is educating a group of older adults about constipation. Which gerontological changes should the nurse include in the session? Select all that apply. 1. Diminished mobility 2. Lowered fluid intake 3. Decreased peristalsis 4. Changes in fiber intake 5. Increased sphincter control 6. Improved smooth muscle tone

1, 3, 4 (laxative overuse, diminished fluid intake, decreased ability to exercise)

The nurse is educating a group of older adults about ways to decrease the risk of developing a fecal impaction. Which risk factors should the nurse include in the session? Select all that apply. 1. Laxative overuse 2. High-fiber content 3. Diminished fluid intake 4. Decreased ability to exercise 5. Inflammatory bowel disease

1, 2, 3, 6 (urine, emesis, diarrhea, nasogastric drainage)

The nurse is educating unlicensed nursing assistive personnel (NAP) about recording output for a client. What fluids should the nurse include in the output for accuracy? Select all that apply. 1. Urine 2. Emesis 3. Diarrhea 4. Nasal drainage 5. Intravenous fluids 6. Nasogastric drainage

4 (30 mL)

The nurse is preparing to remove an indwelling urinary catheter from a client who underwent a prostatectomy a week ago. Which size syringe would be most appropriate for the nurse to use to deflate the retention balloon? 1. 3 mL 2. 5 mL 3. 10 mL 4. 30 mL

2, 4 (creatinine, blood urea nitrogen)

The nurse is reviewing the laboratory data for a client admitted with acute kidney injury. Which values would the nurse expect to see elevated? Select all that apply. 1. Sodium 2. Creatinine 3. Red blood cells (RBC) 4. Blood urea nitrogen (BUN) 5. Glomerular filtration rate (GFR)

1, 3, 5, 6 (catheter size, date and time of insertion, amount of saline in balloon, color, clarity, and amount of urine return)

The nurse just finished inserting an indwelling urinary catheter into a client and is sitting down to document the procedure. Which information should the nurse include in the medical record? Select all that apply. 1. Catheter size 2. Provision of privacy 3. Date and time of insertion 4. Projected date of removal 5. Amount of saline in balloon 6. Color, clarity, and amount of urine return

4 ("This is normal because newborns have looser stools due to immature intestines.")

The parents of a newborn voice concern regarding looser stools that the newborn is experiencing after each breastfeeding. What would be the nurse's best response? 1. "Let's obtain a stool sample and we can run tests." 2. "Have you recently switched formulas for the baby?" 3. "What are the color of the stools the newborn is passing?" 4. "This is normal because newborns have looser stools due to immature intestines."

2 (cecum)

Undigested food first enters the large intestine through which structure? 1. Duodenum 2. Cecum 3. Rectum 4. Sigmoid colon

2 (proximity of urethra to the vagina and anus)

What anatomical feature makes women more prone to urinary tract infections than men? 1. Increased width of the pelvic bones 2. Proximity of the urethra to the vagina and anus 3. Larger bladder 4. Decreased length of the ureters

1, 2, 4 (high blood pressure, altered mental status, fluid retention)

What clinical manifestations might a nurse expect to see if a client has impaired renal function? Select all that apply. 1. High blood pressure 2. Altered mental status 3. Increased urine production 4. Fluid retention 5. Decreased heart rate

3 (increased physical activity promotes normal defecation patterns)

What is the effect of physical activity on normal defecation? 1. Increased physical activity can increase constipation. 2. Decreased physical activity can result in diarrhea. 3. Increased physical activity promotes normal defecation patterns. 4. Physical activity has no effect on defecation patterns.

3 (provides privacy for the client)

What is the purpose of using a drape when inserting a catheter? 1. Reduces the risk of infection 2. Improves lighting for the procedure 3. Provides privacy for the client 4. Helps regulate temperature

4 (glomerular filtration rate)

What is the term for the amount of blood that is filtered in a minute? 1. Creatinine 2. Ammonia 3. Blood urea nitrogen 4. Glomerular filtration rate

1, 2 (monitor intake and output, assess color and clarity of urine)

What should the nurse include in the post-procedure care for a client who underwent a cystoscopy? Select all that apply. 1. Monitor intake and output. 2. Assess color and clarity of urine. 3. Provide only clear liquids. 4. Obtain vital signs every 8 hours. 5. Instruct about the use of contrast dye.

3 (surgical asepsis)

When inserting an indwelling catheter, which level of asepsis is used? 1. Medical asepsis 2. Disinfection 3. Surgical asepsis 4. Low level asepsis

2 (hold the catheter firmly until resistance eases)

When the nurse is inserting a catheter into a male client, resistance is met. What is the first action should the nurse take? 1. Remove the catheter and discard. 2. Hold the catheter firmly until resistance eases. 3. Push the catheter forcefully until it advances. 4. Remove the catheter and try inserting it again.

1, 2, 5 (food allergies, diverticulosis, food intolerance)

Which are common disorders that are primary causes of bowel function? Select all that apply. 1. Food allergies 2. Diverticulosis 3. Pneumonia 4. Seasonal allergies 5. Food intolerance

2, 3, 4 (rash around the anus, excessive gas, intestinal bleeding)

Which are common gastrointestinal symptoms suggestive of food allergy? Select all that apply. 1. Nausea 2. Rash around the anus 3. Excessive gas 4. Intestinal bleeding 5. Severe vomiting

2, 4, 5 (water absorption, vitamin absorption, facilitate stool passage)

Which are functions of the colon? Select all that apply. 1. Lipid digestion 2. Water absorption 3. Protein absorption 4. Vitamin absorption 5. Facilitate stool passage

1, 2, 5 (prevent infection, maintain skin integrity, maintain the free flow of urine)

Which are goals of nursing care for a client with an indwelling urinary catheter? Select all that apply. 1. Prevent infection. 2. Maintain skin integrity. 3. Prevent the client from ambulating. 4. Keep the catheter in as long as possible. 5. Maintain the free flow of urine.

2, 3, 4, 5 (empty the collection bag at least every 8 hours, regularly check connections, provide perineal care when the are becomes soiled, keep the collection bag below the level of the bladder)

Which are measures a nurse can take to help prevent urinary tract infection in clients with an indwelling catheter? Select all that apply. 1. Disconnect the tubing regularly. 2. Empty the collection bag at least every 8 hours. 3. Regularly check connections. 4. Provide perineal care when the area becomes soiled. 5. Keep the collection bag below the level of the bladder. 6. Provide open irrigation as needed.

1, 3, 4 (provide privacy, take a matter-of-fact straightforward approach, control odors to prevent embarrassment)

Which are ways the nurse can promote regular defecation for clients? Select all that apply. 1. Provide privacy. 2. Remind the client that constipation could occur if he or she does not defecate regularly. 3. Take a matter-of-fact straightforward approach. 4. Control odors to prevent embarrassment. 5. Accompany the client and provide encouragement while he or she is attempting defecation.

1, 4, 5 (inflammatory disorders, small bowel obstruction, food positioning)

Which can result in hyperactive bowel sounds? Select all that apply. 1. Inflammatory disorders 2. Paralytic ileus 3. Abdominal surgery 4. Small bowel obstruction 5. Food poisoning

2 (prostatic hypertrophy)

Which condition in older men can result in impaired flow of urine from the bladder into the urethra? 1. Renal calculi 2. Prostatic hypertrophy 3. Cardiovascular disorders 4. Stroke

4 (varies among individuals)

Which describes a normal defecation pattern? 1. Defecation at the same time every day 2. Defecation at least every other day 3. Defecation several times a day 4. Varies among individuals

1 (the amount of filtrate formed by the kidneys per minute)

Which describes the glomerular filtration rate? 1. The amount of filtrate formed by the kidneys per minute 2. The volume of blood that passes through the kidneys in each cardiac cycle 3. The amount of waste removed by the kidney each minute 4. The amount of urine that collects in the bladder per minute

1, 2 (any allergies, history of bladder surgery)

Which health history information should be obtained before a nurse places an indwelling catheter? Select all that apply. 1. Any allergies 2. History of bladder surgery 3. History of heart disease 4. Any problems with constipation 5. Number of pregnancies

1, 2, 4, 5 (show acceptance..., explain..., provide info..., allow the client to ventilate)

Which interventions should the nurse incorporate into the plan of care for a client with a new ostomy that is having difficulty coping with the body change? Select all that apply. 1. Show acceptance when working with the stoma. 2. Explain to the client that his or her sexual relations would not change. 3. Instruct the client that a dressing can be placed over the ostomy during sexual relations. 4. Provide information regarding support groups available for clients with ostomies. 5. Allow the client to ventilate feelings about having a new colostomy and how it changes his or her life. 6. Show the client how to take care of the ostomy, including changing the bag and wafer.

1, 3, 4 (eliminate caffeine from the diet, stop smoking, lose weight)

Which interventions should the nurse instruct the client to perform to decrease the incidence of urinary incontinence? Select all that apply. 1. Eliminate caffeine from the diet. 2. Limit the intake of fluids. 3. Stop smoking. 4. Lose weight. 5. Increase the use of artificial sweeteners.

3 (hydrogen)

Which ion controls acid-base balance? 1. Sodium 2. Oxygen 3. Hydrogen 4. Potassium

3 (1.02)

Which is a normal specific gravity for urine? 1. 0.12 2. 1.30 3. 1.02 4. 13.0

3 (can be removed immediately and client can void normally)

Which is an advantage of intermittent catheterization over indwelling catheters? 1. Convenience to the client 2. Decreased risk of infection 3. Can be removed immediately and client can void normally 4. Convenient for the nurse

4 (risk for constipation related to immobility)

Which is an appropriate elimination-related nursing diagnosis for a client who is on bedrest following surgery, and is also taking opioid pain medications? 1. Risk for bowel incontinence 2. Risk for infection related to diarrhea 3. Altered tissue integrity related to incontinence 4. Risk for constipation related to immobility

2 (constipation)

Which is the result of the passage of stool through the colon being slowed? 1. Diarrhea 2. Constipation 3. Distention 4. Ileus

2 (fecal occult blood test)

Which lab test can be done at the bedside and requires the least amount of stool specimen? 1. Testing for parasites 2. Fecal occult blood test 3. Clostridium difficile testing 4. Testing for infectious processes

1, 3 (iron, opioids)

Which medications would the nurse instruct the client with chronic constipation to avoid taking? Select all that apply. 1. Iron 2. Aspirin 3. Opioids 4. Laxatives 5. Antibiotics

2 (perceived constipation)

Which nursing diagnosis applies to a client who feels it is important to have a bowel movement every day, and resorts to taking laxative suppositories or enemas to facilitate this? 1. Dysfunctional gastrointestinal motility 2. Perceived constipation 3. Irritable bowel syndrome 4. Chronic constipation

3 (amount of saline in balloon)

Which piece of information is most important for the nurse to obtain prior to removing an indwelling urinary catheter? 1. Date of insertion 2. Type of catheter material 3. Amount of saline in balloon 4. Allergy to betadine or shellfish

3 (illeostomy)

Which procedure produces a surgical opening in the abdomen and bypasses the large intestine entirely? 1. Sigmoid colostomy 2. Kock pouch 3. Ileostomy 4. Loop colostomy

1, 4, 5 (increase fluid intake, increase physical activity, do not ignore the urge to defecate)

Which should be included in client teaching to support normal bowel elimination? Select all that apply. 1. Increase fluid intake. 2. Limit fiber intake. 3. Increase caffeine intake. 4. Increase physical activity. 5. Do not ignore the urge to defecate.

1, 2, 5 (cramping, abdominal distention, sharp abdominal discomfort)

Which symptoms characterize flatulence? Select all that apply. 1. Cramping 2. Abdominal distention 3. Rectal bleeding 4. Heartburn sensation 5. Sharp abdominal discomfort

4 (sigmoid colostomy)

Which type of bowel diversion would result in a solid stool? 1. Ileostomy 2. Kock pouch 3. Ileoanal reservoir 4. Sigmoid colostomy

4 (return-flow enema)

Which type of enema may be ordered to help a client pass flatus and relieve abdominal distention? 1. Oil-retention enema 2. Medicated enema 3. Nutritive enema 4. Return-flow enema

4 (sigmoid colostomy)

With which type of bowel diversion is the client most likely to have control over bowel elimination and not need to wear an appliance? 1. Ileostomy 2. Ascending colon colostomy 3. Transverse colon colostomy 4. Sigmoid colostomy