NURS 138: Elimination EAQS

When assessing a client during peritoneal dialysis, a nurse observes that drainage of the dialysate from the peritoneal cavity has ceased before the required volume has returned. What should the nurse instruct the client to do? 1 Drink a glass of water 2 Turn from side to side 3 Deep breathe and cough 4 Rotate the catheter periodically

2 Turning from side to side will change the position of the catheter, thereby freeing the drainage holes of the tubing, which may be obstructed. Drinking a glass of water and deep breathing and coughing do not influence drainage of dialysate from the peritoneal cavity. The position of the catheter should be changed only by the primary healthcare provider.

After reviewing the urinalysis reports of a group of clients, a nurse suspects a client to have kidney disease. Which client's findings support the nurse's suspicion?

The normal range of serum creatinine lies between 0.6 and 1.2 mg/dL. The serum creatinine concentration of client C is 2.5 mg/dL, which is greater than the normal value, and indicates renal impairment. Therefore the laboratory findings of client C support the nurse's suspicion. A serum creatinine concentration of 1.1 mg/dL in client A is a normal finding. The normal range of blood urea nitrogen (BUN) is 10 to 20 mg/dL; therefore, the urinalysis reports for clients B and D are normal.

Why would a client with acquired immunodeficiency syndrome (AIDS) be prescribed diphenoxylate hydrochloride? 1 To manage pain 2 To manage diarrhea 3 To manage candidal esophagitis 4 To manage behavioral problems

2 Diphenoxylate hydrochloride is an antidiarrheal drug prescribed to clients with AIDS to manage frequent diarrhea experienced by a client with AIDS. Opioid analgesics such as tramadol are used to manage pain. Ketoconazole can be used to treat candidal esophagitis associated with AIDS. Behavioral problems are managed with psychotropic drugs.

Which organ-specific autoimmune disorder is associated with a client's kidney? 1 Graves' disease 2 Addison's disease 3 Goodpasture syndrome 4 Guillain-Barré syndrome

3 Goodpasture syndrome is an autoimmune disorder associated with the client's kidney. Graves' disease and Addison's disease are autoimmune disorders associated with the endocrine system. Guillain-Barré syndrome is an autoimmune disorder associated with the central nervous system.

A client with ascites is scheduled for a paracentesis. To prepare the client for the abdominal paracentesis, what should the nurse do? 1 Shave the client's abdomen. 2 Medicate the client for pain. 3 Encourage the client to drink fluids. 4 Instruct the client to empty the bladder

4 Emptying the bladder of urine keeps the bladder in the pelvic area and prevents puncture when the abdominal cavity is entered. Shaving the client's abdomen and medicating the client for pain are not necessary. Encouraging fluids is unsafe; the bladder will rise into the abdominal cavity and may be punctured.

A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the infant's first stool. What should the nurse do next? 1 Document the stool in the infant's record. 2 Send the stool to the laboratory per protocol. 3 Assess the infant for an intestinal obstruction. 4 Notify the health care provider that a tarry stool has been passe

1 The neonate's first stool, which is thick and greenish-black, is called meconium; the appearance of meconium is an expected occurrence that should be documented. This stool is expected; there is no reason to suspect intestinal obstruction. Meconium stool on the first day of life is expected and does not require further examination. Meconium is not indicative of bleeding; it contains bile and other waste products produced by the fetus. Passage of meconium does not require notification of the health care provider.

The nurse is reviewing a client's current medication therapy and suspects hematuria. Which medication is responsible for the client's condition? 1 Warfarin 2 Cimetidine 3 Phenazopyridine 4 Nitrofurantoin

1 Warfarin is an anticoagulant. Anticoagulants may cause hematuria, which is the presence of blood in the urine. Cimetidine is an antihistamine. Antihistamines affect the normal contraction and relaxation of the urinary bladder. Phenazopyridine and nitrofurantoin cause urine discoloration.

The nurse is caring for a client 4 days after the client had a cystectomy and formation of an ileal conduit. After observing mucous threads in the client's urine, what should the nurse do? 1 Recognize that this is an expected response. 2 Obtain a specimen for culture and sensitivity. 3 Report this to the primary healthcare provider immediately. 4 Increase the client's fluid intake for the next 12 hours.

1 This response is expected after a diversion because mucus is secreted continually by the intestinal mucosa. Reporting this to the primary healthcare provider immediately is not necessary; mucus is expected with an ileal conduit. Obtaining a specimen for culture and sensitivity is not necessary. At this point postsurgically the mucus is not an indication of infection. Although fluids should be encouraged to maintain urine flow, increasing the client's fluid intake for the next 12 hours will not eliminate mucus, which is discharged continually from the intestinal segment.

Which dietary changes does the nurse suggest for a client who has diarrhea associated with human immunodeficiency virus (HIV disease)? Select all that apply. 1 "Eat more fatty food." 2 "Eat much less roughage." 3 "Drink two cups of coffee daily." 4 "Eat more spicy and sweet food." 5 "Drink plenty of fluids between meals."

2, 5 Clients infected with the HIV virus often suffer from diarrhea. Roughage should be limited in the diet of a client who has diarrhea associated with HIV disease, as it is not easy digestible. Drinking plenty of fluids helps to compensate for the fluid loss. Fatty foods are avoided as they alter the process of digestion. Coffee is avoided as it stimulates the gastrointestinal tract and leads to diarrhea. Spicy and sweet foods are avoided as they trigger the gastrointestinal tract and acidify the stomach contents that lead to diarrhea.

A client returns from surgery with a permanent colostomy. During the first 24 hours the colostomy does not drain. What does the nurse determine is the probable cause of this response, and what is the treatment? 1 Intestinal edema after surgery; apply ice 2 Presurgical decrease in fluid intake; encourage fluids 3 Absence of gastrointestinal motility; continue to monitor 4 Effective functioning of nasogastric suction; irrigate stoma

3 The colostomy starts functioning when peristalsis returns. Intestinal manipulation and the depressive effects of anesthesia and analgesics cause absence of gastrointestinal motility; this is an expected response, so continue to monitor. Edema will not interfere totally with peristalsis; there should be some output; ice will damage the stoma. A presurgical decrease in fluid intake will not influence gastric motility 24 hours later. A nasogastric tube decompresses the stomach; it does not directly influence intestinal motility at this time; irrigation is not necessary.

A nurse is caring for an elderly client who has constipation. Which independent nursing intervention helps to reestablish a normal bowel pattern? 1 Administer a mineral oil enema. 2 Offer 1 cup of fluid every hour. 3 Manually remove fecal impactions. 4 Offer a cup of prune juice.

4 Prune juice does not require a primary healthcare provider's order and helps to promote bowel movement because it contains sorbitol that increases water retention in feces. Administration of a mineral enema requires a prescription from a primary healthcare provider. Encouraging the client's fluid intake by offering 1 cup of fluid every hour is helpful in preventing constipation but not as effective in resolving constipation as prune juice. Removing impactions does not establish regular bowel patterns.

What does the nurse find in the laboratory report of a client who is suspected of having a urinary disorder and is on steroid therapy? 1 Increased red blood cells count 2 Increased sodium count 3 Increased serum creatinine levels 4 Increased blood urea nitrogen levels

4 Steroid therapy may be used to treat urinary disorders; however, it may cause the blood urea nitrogen (BUN) levels to elevate. Increased red blood cell count occurs in polycythemia. Increased sodium does not occur with steroid use. An increase in serum creatinine levels indicates kidney impairment.

The nurse is assisting a primary healthcare practitioner to perform an examination of the reproductive tract of a female client. Which nursing action is beneficial for the client? 1 Providing judgmental support to the client 2 Placing the client to move her hands away from the body 3 Asking the client to remove her drape while undergoing the test 4 Asking the client to empty the bladder before the examination

4 The client should empty her bladder before the examination to ensure appropriate test results. The nurse should provide nonjudgmental support and relaxation techniques to the client to increase her comfort during the examination. The client should place her arms towards her sides to allow better relaxation of the abdominal muscles. The client should be draped adequately to provide modesty throughout the examination. Drapes will be removed and replaced after examining the specific area.

A client is receiving hypertonic tube feedings. What should the nurse consider to be the main reason this client may experience diarrhea? 1 Increased fiber intake 2 Bacterial contamination 3 Inappropriate positioning 4 High osmolarity of the feeding

4 The increased osmolarity (concentration) of many formulas draws fluid into the intestinal tract, which can cause diarrhea; such feedings may need to be diluted initially until the client develops tolerance or is changed to a more iso-osmolar strength formula. Formulas frequently have reduced fiber content. Bacterial contamination is not a factor if the manufacturer's recommendations are followed. Inappropriate positioning may increase the risk for aspiration, but it does not cause diarrhea.

A nurse identifies a moderate amount of bright red blood in a client's gastric drainage four hours after a subtotal gastrectomy. What should the nurse do first? 1 Clamp the nasogastric tube. 2 Irrigate the tube gently with normal saline. 3 Record the observation and continue to monitor the drainage from the tube. 4 Reduce the pressure of the suction and record observations of the drainage characteristics.

Record the observation and continue to monitor the drainage from the tube. Some bright red blood at this point is an expected finding that should be monitored; large amounts of blood or bleeding should be reported immediately. Clamping the nasogastric tube is contraindicated; secretions will accumulate and cause pressure on the suture line. Also, clamping the tube prevents observation of gastric drainage. If the tube is draining, there is no need to irrigate; also, irrigations are traumatic. Reducing suction pressure allows secretions to accumulate and causes pressure on the suture line.

A client is admitted to the postanesthesia care unit after abdominal hysterectomy. Which assessment should the nurse report to the primary healthcare provider immediately? 1 Decreased urine output 2 Apical pulse of 90 beats/min 3 Increased drainage from the nasogastric tube 4 Serosanguineous drainage on the perineal pad

1 Accidental ligation of a ureter is a serious complication of total abdominal hysterectomy. A decrease in urine output should be reported immediately to the surgeon. An apical rate of 90 beats/min falls within expected limits but should be evaluated in relation to the client's previous vital signs. A nasogastric tube is not inserted routinely. Serosanguineous drainage on the perineal pad is expected.

A primary healthcare provider prescribes three stool specimens for occult blood for a client who complains of blood-streaked stools and a 10-pound (4.5 kg) weight loss in one month. To ensure valid test results, what instructions should the nurse give the client? 1 Avoid eating red meat before testing 2 Test the specimen while it is still warm 3 Discard the day's first stool and use the next three stools 4 Take three specimens from different sections of the fecal sample

1 Red meat can react with reagents used in the test to cause false-positive results. Testing the specimen while it is still warm may apply for testing for ova and parasites, but not for occult blood. If the correct procedure is followed, discarding the first specimen is unnecessary. Random stool testing can be done but must be on three different bowel movements during the screening period.

After having a transverse colostomy, the client asks what physical effect the surgery will have on future sexual relationships. Which information should the nurse include in a teaching plan for this client? 1 "You will be able to resume usual sexual relationships." 2 "Surgery will temporarily decrease your sexual impulses." 3 "Your sexual activity must be curtailed for several weeks." 4 "Partners should be told about the surgery before any sexual activity."

1 Surgery on the bowel has no direct anatomic or physiologic effect on sexual performance. However, psychologic factors may hamper this function, and the nurse should encourage verbalization. Although it may take several months to resume satisfying sexual relationships, the surgery has no direct physiologic effect. There is no reason why sexual activity must be curtailed. Although a partner should understand the nature of the surgery, the focus at this time should be on the client.

A 12-year-old boy with nephrotic syndrome is in remission for several months. One day the mother calls the clinic to report that for the past week her child's skin has a pale, muddy appearance; his appetite is poor; and he has been unusually tired after school. In light of the mother's description, what does the nurse suspect? 1 Impending renal failure 2 Excessive activity at school 3 Development of a viral infection 4 Nonadherence to the medication protocol

1 The anemia associated with renal failure accounts for the pallor and decreased energy; the decreased appetite and decreased energy are related to the accumulation of toxic wastes. Excessive activity should not cause the signs and symptoms identified by the mother if the child is in remission. An increased temperature will probably be present with an infection; an infection does not cause a muddy pallor. Discontinuing the corticosteroids and diuretics, if prescribed, might result in a recurrence of edema in the steroid-dependent child; it is not a sign of renal failure.

Which laboratory finding is suggestive of mild kidney disease in male clients? 1 Serum creatinine - 0.9 mg/dL 2 Urinary albumin - 24 mg/mmol 3 Blood urea nitrogen (BUN) - 18 mg/dL 4 Blood urea nitrogen (BUN)/creatinine ratio - 23

2 Increased levels of albumin in the urine indicate mild or moderate kidney disease. The normal levels of albumin in the urine range between 2.0 and 20 mg/mmol in men and between 2.8 and 28 mg/mmol in women. An albumin level of 24 mg/mmol is higher than the normal range for men. Therefore a urinary albumin of 24 mg/mmol suggests mild kidney failure. The normal levels of serum creatinine range between 0.6-1.2 mg/dL in men and between 0.5-1.1 mg/dL in women. Therefore a serum creatinine value of 0.9 mg/dL is normal. Blood urea nitrogen (BUN) in the range of 10-20 mg/dL is normal. Therefore a BUN value of 18 mg/dL is a normal finding. The normal range of a BUN/creatinine ratio is between 6 and 25. Therefore a BUN/creatinine ratio of 23 is a normal value.

Which serum laboratory values in a client with urinary problems may indicate the risk of developing muscle weakness and cardiac arrhythmias? 1 Calcium of 9.5 mg/dL (2.375 mmol/L) 2 Potassium of 7.02 mEq/L (7.02 mmol/L) 3 Bicarbonate of 22.8 mEq/L (22.8 mmol/L) 4 Phosphorus of 4.1 mg/dL (1.3243 mmol/L)

2 The normal level of serum potassium is between 3.5-5.0 mEq/L (3.5 and 5.0 mmol/L). Elevated potassium levels greater than 6 mEq/L (mmol/L) can lead to muscle weakness and cardiac arrhythmias. The normal levels of serum phosphorus are between 2.4-4.4 mg/dL (0.78 and 1.42 mmol/L). The normal levels of serum calcium are usually between 8.6-10.2 mg/dL (2.15 and 2.55 mmol/L). The normal level of serum bicarbonate is between 22 and 26 mEq/L or mmol/L. These findings are not associated with the risk of developing muscle weakness and cardiac arrhythmias.

A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that preprocedure prescriptions will include what? 1 Providing instructions about restraints used during the procedure 2 Administering a Fleet enema 1 hour before the procedure 3 Encouraging increased intake of clear fluids 4 Administering morphine 30 minutes before the procedure

2 To facilitate visualization of the rectum and the sigmoid colon, the lower colon must be emptied immediately before the procedure. A Fleet or tap water enema should be used. Restraints are not typically used during the procedure. The client will be kept nothing by mouth (NPO) for at least 8 hours before the procedure. Morphine is not typically used as a preoperative medication before a sigmoidoscopy.

A client has a new colostomy. The nurse has provided teaching related to when the client should irrigate the colostomy. Which client statement indicates correct understanding of the teaching? 1 "After it gets done healing in a few weeks, I will begin irrigating it just before going to bed each day." 2 "It will need to be irrigated each morning before I can eat any food." 3 "I plan to irrigate it in the late morning, the same time I had a bowel movement every day before I had my surgery." 4 "I can wait to start irrigating it until after I have gotten used to this bag and change in lifestyle."

3 Although most people defecate after breakfast because ingestion of food on an empty stomach initiates the gastrocolic reflex, not all people defecate at this time. Irrigation should be performed at the time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Irrigations should be performed at the same time the client routinely defecated before the colostomy, to maintain continuity in lifestyle. Clients can eat before irrigating the colostomy. An irrigation cannot be postponed until the client accepts the altered body image, because this may take weeks or months.

An infant has exstrophy of the bladder. What does the nurse anticipate that the primary healthcare provider will prescribe to protect the exposed bladder area? 1 Antibacterial ointment 2 Pediatric urine collector 3 Warm, moist compresses 4 Sterile nonadherent dressing

4. Sterile nonadherent dressings help prevent infection and ulceration of the surrounding skin. Seepage of urine will prevent ointments from remaining on the exposed mucosa for longer than a few moments; also, ointments may irritate the mucosa, resulting in bleeding. Pediatric urine collectors will not adhere because of the moist environment; also, the adhesive backing is irritating to the skin. Warm, moist compresses are contraindicated, because they will increase moisture and temperature in the area, enhancing the growth of microorganisms and the potential for infection.