Fundys Elimination

A nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to:

breathe deeply.

The nurse is assessing a client who has benign prostatic hypertrophy (BPH). The nurse should determine if the client has which symptom?

difficulty starting the urinary stream

Which nursing intervention is most important in preventing postoperative complications?

early ambulation

Which question should the nurse ask first when obtaining a history from the parent of a school-age child with a fever, malaise, and swelling around the eyes?

"Does the child urinate as much as usual?"

Which statement indicates that the client understands the home care of a colostomy?

"I should be able to establish a regular pattern of elimination with my colostomy."

A nurse is caring for a client who is an employee in the hospital. The client has recently received a diagnosis of genital herpes and is being treated for a urinary tract infection (UTI). A co-worker asked the nurse how the employee is doing. What is the nurse's best response?

"I'll be sure to tell the client you said hello"

The wife of a terminally ill client asks the nurse, "Why is my husband having frequent bowel movements if he is not eating?" What should the nurse tell the wife?

"The intestines still produce some waste products even when a person is not eating."

After teaching the mother of a young girl about measures to help prevent urinary tract infections, which statement by the mother indicates successful teaching?

"We'll make sure she takes a water bottle with her to afterschool events."

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take?

Continue to monitor and record hourly urine output.

A registered nurse and a nursing assistant are caring for a group of clients. Which client's care may safely be delegated to the nursing assistant?

A client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids.

The client who is in Buck's traction is constipated. A plan of care that incorporates which breakfast would be most helpful in reestablishing a normal bowel routine?

An orange, raisin bran and milk, and wheat toast with butter

A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client to do?

Empty the bladder every 2 to 3 hours.

A preschooler has vomiting, diarrhea, and a potassium level of 3 mEq/L (3 mmol/L). Which prescribed order will the nurse implement first?

I.V. infusion of 500 ml of dextrose 5% in water and half-normal saline solution with 20 mEq (20 mmol/L) of potassium chloride at 100 ml/hr

When a client with an indwelling urinary catheter wants to walk to the hospital lobby to visit with family members, the nurse teaches the client how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?

The client keeps the drainage bag below the bladder at all times.

A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which nursing observation indicates this client is ready to be discharged?

The client voids 500 mL of urine.

Which teaching instructions by the nurse is appropriate for a client with constipation?

The client will consume foods high in fiber.

A client developed cardiogenic shock after a severe myocardial infarction and has now developed acute renal failure. The client's family asks the nurse why the client has developed acute renal failure. What should the nurse tell the family? "Because of the cardiogenic shock, there is:

a decrease in the blood flow through the kidneys."

Which client is at highest risk for developing a urinary tract infection?

a man with an indwelling urinary catheter

Which intervention would be least appropriate for a client who is in a double hip spica cast?

advising the client to eat large amounts of cheese

A 13-year-old client is being evaluated for possible Crohn's disease. The nurse expects to prepare the client for which diagnostic study?

colonoscopy with biopsy

The primary reason for lubricating the urinary catheter generously before inserting the catheter into a male client is to prevent which problem?

friction along the urethra when the catheter is being inserted..

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:

incorporate the client's toileting schedule into the pattern of his wandering.

Using Abraham Maslow's hierarchy of human needs, the nurse assigns highest priority to which client need?

inserting a Foley catheter

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal?

keeps the new urethra from closing

A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed?

laxative

A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate?

limiting fluid intake to 1,000 mL/day

A nurse is caring for an 8-year-old girl with multiple chronic urinary tract infections. The child's parents appear protective, never leaving their daughter's side. While the nurse helps the child's mother provide morning care, the child states, "My uncle doesn't clean me that way." Her mother becomes visibly upset and gives the girl a stern warning not to discuss the matter. She states, "Don't tell anyone about that again." The nurse has a legal responsibility to:

notify the nursing supervisor and the authorities of the possibility of abuse.

Which aspects of client care would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

obtaining a urine specimen for a culture and sensitivity analysis from a client who has an indwelling urinary catheter inserted

A nurse is caring for a client with history of chronic intestinal irritation. The client asks, "Is there any type of colostomy where I would not need a continuous colostomy bag?" Indicate the location where a client could have an ostomy that eventually might not require wearing an ostomy bag.

sigmoid colon

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

urinary retention

A client with fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the

middle stream of urine from the bladder.

the client has been taking magnesium hydroxide to control hiatal hernia symptoms. The nurse should assess the client for which condition most commonly associated with the ongoing use of magnesium-based antacids?

diarrhea

Nitrofurantoin, 75 mg four times per day, has been prescribed for a client with a lower urinary tract infection. The medication comes in an oral suspension of 25 mg/5 mL. How many milliliters should the nurse administer for each dose? Record your answer using a whole number.

15

The physician orders docusate sodium 100 mg at bedtime for a primiparous client after vaginal delivery of a term neonate after a midline episiotomy. The nurse instructs the client to expect which of the following results from taking the medication?

Softening of the stool.

While assessing the episiotomy site of a primiparous client on the first postpartum day, the nurse observes a fairly large hemorrhoid at the client's rectum. After instructing the client about measures to relieve hemorrhoid discomfort, which statement indicates the need for additional teaching?

"I should lie on my back as much as possible to relieve the pain."

A nurse is teaching a client what to expect following a barium enema. Which client statement indicates a need for further teaching?

"I should limit my fiber intake for 1 to 2 weeks following the procedure."

A client with inflammatory bowel disease undergoes an ileostomy. On the first day after surgery, the nurse notes that the client's stoma appears dusky. How should the nurse interpret this finding?

Blood supply to the stoma has been interrupted.

A nurse asks a client who had abdominal surgery 3 days ago if they have moved their bowels since surgery. The client states, "I haven't moved my bowels, but I am passing gas." How should the nurse intervene?

Encourage the client to ambulate at least three times per day.

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

Establish a regular voiding schedule.

The nurse teaches a primigravid client how to do Kegel exercises. What does the nurse explain is the expected outcome of these exercises?

strengthening the perineal muscles

The nurse is instructing an unlicensed assistive personnel (UAP) to collect a urine specimen from an indwelling catheter. Which statement indicates that the UAP understands the instructions?

"I'll get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container."

A client is admitted to the health care facility with bowel obstruction secondary to colon cancer. The nurse obtains a health history, measures vital signs, and auscultates for bowel sounds. Which step of the nursing process is she performing?

Assessment

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do?

Check on the client at regular intervals to ascertain the need to use the bathroom.

A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000-mL intake. What should the nurse do first?

Assess for bladder distention.

A pregnant client in her third trimester asks why she needs to urinate frequently again, as she did during the first trimester. What should the nurse tell her?

This symptom is normal and results from the fetus exerting pressure on the bladder.

A client's serum ammonia level is elevated, and the health care provider (HCP) prescribes 30 mL of lactulose. Which effect is common for this drug?

increased bowel movements