Saunders NCLEX-PN Elimination

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? Select all that apply.

1,3 1.Placing the scan head on the symphysis pubis and aiming toward the bladder 2.Pressing and holding the done button to display the volume measurement and print results 3.Applying a generous amount of transmission/conductivity gel across the client's abdomen 4.Pressing the gender button to select the male setting and wiping the scan head with an alcohol pad 5.Turning on the scanner by pressing the on/off button and then the scan button to turn on the scanning screen 6.Assisting the client to a supine position with head elevated on a pillow and exposing the client's lower abdomen

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply.

1,3,4,5 1.Maintain adequate fluid intake of 2 quarts. 2.Urinate regularly every 8 hours during the day. 3.Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. 4.Take all discharge medication as prescribed including antibiotics, and notify your primary health care provider if symptoms or signs of a UTI reappear. 5.Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating.

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.

1,3,4,6 1.Apply disposable gloves. 2.Place the client in the right Sims' position. 3.Lubricate the enema tube and insert it approximately 4 inches. 4.Clamp the tubing if the client expresses discomfort during the procedure. 5.Hang the enema solution container 24 inches above the client's anus. 6.Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C).

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Advance the catheter to the bifurcation and inflate the balloon.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

"I need to decrease fiber in my diet."

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. Select all that apply.

1,2,3,4 1.Check the bladder for distention. 2.Review intake and output record. 3.Check to ensure drainage tubing is not kinked. 4.Ask the client about bladder spasms and discomfort. 5.Raise the drainage bag to the height of the bladder. 6.Deflate the balloon of the catheter, advance the catheter 2 cm, and reinflate the balloon.

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. Select all that apply.

1,2,3,4 1.Check the bladder for distention. 2.Review intake and output record. 3.Check to ensure drainage tubing is not kinked. 4.Ask the client about bladder spasms and discomfort. 5.Raise the drainage bag to the height of the bladder. 6.Deflate the balloon of the catheter, advance the catheter 2 cm, and reinflate the balloon.

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? Select all that apply.

1,2,3,4 1.Increase your fluid intake. 2.Include more fiber in your diet. 3.Ferrous sulfate changes the color of stool to black. 4.Iron slows colonic acid and often leads to constipation. 5.Use an enema every other day if you don't have a bowel movement. 6.Signs of constipation include not having a bowel movement every day.

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? Select all that apply.

1,2,3,4,5 1.Character of drainage 2.Presence of blood clots 3.Amount of drainage emptied 4.Client complaint of pain/spasms 5.Type and amount of irrigation fluid used 6.Frequency of emptying the drainage bag

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply.

2,3 1. Obtain the bladder scan before the client voids. 2. Have the client void and then perform the bladder scan. 3. If residual urine is less than 100 mL, continue to monitor. 4. Reduce oral fluid intake to decrease amount of residual urine. 5. Straight catheterize the client if 100 mL of urine is viewed on the scan. 6. Notify the primary health care provider immediately if 30 mL of urine is viewed on the scan.

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

2,4,5,6 1.Change the appliance daily. 2.Empty pouch when ⅓ to ½ full. 3.The stoma should be a dry pale pink. 4.The stoma should be moist and pink to red. 5.The skin barrier should be within 1⁄16 to ⅛ inch of the stoma. 6.Change the appliance about every 3 days, or sooner, if it is leaking effluent.

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.

250 mL

An older client complains of chronic constipation. Which instructions should the nurse reinforce with the client? Select all that apply.

3,5 1.Include rice and bananas in the diet. 2.Increase the intake of sugar-free products. 3.Increase fluids to at least eight glasses a day. 4.Increase various potassium-rich foods in the diet. 5.Respond in a timely manner to the urge to defecate.

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

4,6 1.Assess the stoma and skin. 2.Remove the used pouch and barrier. 3.Perform hand hygiene and don gloves. 4.Lightly scrub the stoma with soap and water. 5.Press the adhesive backing of the pouch against the skin. 6.Cut the opening on the appliance ½ inch larger than stoma.

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx?

Long- term silicon size 16Fr 5mL balloon with sterile water

The client is to receive a soapsuds enema. Which is the best position for administering an enema?

Sims position

The nurse should recognize that which type of enema has the highest risk of water intoxication?

Tap water

Which factors contribute to the problem of stress incontinence? Select all that apply.

1,2 1.Obesity 2.Sneezing 3.Nulliparity 4.Performing Kegel exercises 5.Voiding at frequent intervals

A client has been diagnosed with functional incontinence. Which interventions are most appropriate to care for this type of incontinence? Select all that apply.

1,2,3,6 1.Schedule toileting every 2 hours. 2.Modify clothing for easy removal. 3.Assess environment for obstacles. 4.Decrease fluid intake to 1500 mL/day. 5.Obtain prescription for catheterization to eliminate embarrassment. 6.Set up schedule of cues such as mealtimes, awakening, and bedtime.