Bowel and Urinary ELimination

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure?.

Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake

Reflex incontinence is caused by

damage to motor and sensory tracts in the lower spinal cord secondary to trauma.

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply.

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?"

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful?

Digital removal of stool may cause parasympathetic stimulation

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician?

Prolapsed stoma

The nurse is preparing to insert a nasogastric (NG) tube into an adult client. Place the following steps in the correct order. Use all options.

Place the client in high Fowler's position. Measure the intended length to insert the NG tube. Lubricate the tube tip with water-soluble lubricant. Direct the tube upward and backward along the floor of the nose. Instruct the client to place the chin onto the chest. Advance the tube while the client swallows.

The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client?

Sims

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?

The client has an enlarged prostate

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

The client will have to wear an external appliance to collect urine.

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet?

a diet lacking in fruits and vegetables

A nurse is documenting the eating habits of a client who wants to include more fiber in the diet. Which is the best statement to include?

Plans to eat a snack of fruit twice per day

An obstruction that blocks the passage of flatus and intestinal chime or feces is a primary cause of

abdominal distention. Paralytic ileus and abdominal tumors are types of bowel obstruction that produce distention.

Citrus fruits, such as grapefruit, are good choices for a client with

constipation as they are rich in soluble fiber pectin, which increases gastrointestinal motility.

If the client cannot retain the enema solution for an adequate amount of time,

place the client on the bedpan in a supine position while receiving the enema. Elevate the head of the bed 30 degrees for the client's comfort

The most common types of solutions used for cleansing enemas are

tap water, normal saline, soap solution, and hypertonic solution

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?

"Let's review the types of fluids that your child drinks in the morning."

The nursing instructor is having a discussion related to the gastrointestinal (GI) system. Which statements by the students would indicate that the discussion was effective? Select all that apply.

"Movement of the colon is stimulated by the parasympathetic nervous system." "The last part of the large intestine is the rectum, not the anus." "The stool becomes hard if it remains in the large intestine too long."

The nurse has presented an educational in-service about caring for clients who have newly created ostomies. The nurse asks participants, "How will you know when a client begins to accept the altered body image?" Which responses by participants indicates a correct understanding of the material? Select all that apply.

"The client is willing to look at the stoma." "The client makes neutral or positive statements about the ostomy." "The client expresses interest in learning self-care."

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test?

"This test detects heme, an iron compound in blood within the stool."

The client is preparing to obtain a clean-catch midstream urine specimen. List in order the steps needed to complete the diagnostic test.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into stool. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24-hour specimen

The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing into the rectum?

3 in

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? Administer the solution gradually over

5 to 10 minutes.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel?

Antidiarrheal agent

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?

Anuria

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action?

Attempt to irrigate the NG tube with water or normal saline

The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment will the nurse perform to gather additional information?

Auscultate for bowel sounds

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing?

Avoid more than 250 mg

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

Bedside commode

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis?

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

Which symptom will have a great impact on the extracellular fluid for water conservation?

Burns

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure?

Collect 15 to 30 mL of the client's liquid stool.

A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women?

Contract the pubic muscles for 3 seconds, then relax.

A client asks, "Why do some foods, like corn, come out undigested in my feces?" Which is the nurse's best response?

Corn is high in cellulose, which is an insoluble fiber that the body cannot digest.

A nurse assessing an older adult client finds that the client has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause?

Decreased bladder contractility

A paraplegic man receives care in the rehabilitation facility. He confides in a nurse that he has trouble controlling his bowel movements. He tends to normally stool 6 to 8 times per day. This has caused the skin around his rectum to become irritated. Which is not an appropriate NANDA-I diagnosis for this client?

Diarrhea r/t decreased muscle tone and sphincter control

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube?

Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply.

Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body. Instruction should include drying the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum, as well as taking showers instead of baths.

The nurse is creating a plan of care for an older adult client at risk for constipation. Which intervention by the nurse will decrease this risk?

Encourage physical activity to improve bowel regularity.

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

First thing in the morning

A nurse is ordered to perform digital removal of stool for a client with stool impaction. Which action is an appropriate step in this procedure?

Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client?

Impaired Skin Integrity related to urinary bladder infection and dehydration The nursing concern is his excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary Tract Infection is not a nursing diagnosis, rather a medical diagnosis.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan?

Increase fiber slowly over a period of time to prevent gas.

A nurse is caring for a client who has a large, hardened mass of stool that is interfering with defecation, making it impossible for the client to pass feces voluntarily. Which recommendation(s) will the nurse provide the client to prevent future fecal impaction from occurring? Select all that apply.

Increasing fluid intake Increasing daytime exercise · The client will need to prevent constipation by increasing fluid intake, exercising, and toileting at regular intervals. While laxatives can be effective in the short term, they can also cause dependence

The nurse is preparing to remove stool digitally for a client who is constipated. Which steps are included in this process? Select all that apply

Insert gloved finger gently into anal canal, pointing toward the umbilicus. Generously lubricate index finger of dominant hand with water-soluble lubricant. Instruct client to bear down, if possible, while extracting feces to ease in removal. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

The type of stool that will be expelled into the ostomy bag by a client who has undergone surgery for an ileostomy will be:

Liquid

The nurse is changing a client's ostomy appliance and observes that the peristomal skin is excoriated. What would be the nurse's priority intervention in this situation?

Make sure that the appliance is not cut too large. -The priority action of the nurse would be to assess the situation to determine the possible cause. This will involve making sure that the appliance is not cut too large. Skin that is exposed inside of the ostomy appliance will become excoriated from the acidity of the stool. The nurse would not need to clean the outside of the bag because the peristomal skin is around the stoma and not exposed to the outside of the bag. if the fecal material is outside the bag, then the bag was not applied correctly and it leak

A nurse prepares a client with a recently created ileal conduit to be discharged from the hospital. Which is an expected assessment finding?

Mucus in the urine is a normal finding.

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter.

A nurse is assessing the stoma of a client who had an ostomy. Which assessment finding(s) necessitates further evaluation of the stoma? Select all that apply.

Pallor of the stoma Purple-blue color of the stoma Irritation and dryness at the stoma site Yellow discharge at the stoma site Bleeding at the stoma site

Which medical diagnosis is most likely to necessitate testing for fecal occult blood?

Peptic Ulcer

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client

Regular toileting routine

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure?

Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. The nurse would not position the client on the left side in the Sims' position. The nurse would administer the solution over 5 to 10 minutes, depending on the volume. The nurse would not encourage the client to hold the solution for at least 5 to 15 minutes when the urge to defecate becomes strong.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action?

Stop the procedure, monitor heart rate and blood pressure

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

Straight catheter

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence?

Stress

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing?

Stress incontinence

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred?

The NG tube is in the client's airway.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal?

The client is acutely confused and has been diagnosed with delirium A client who is acutely confused is likely unable to manipulate a urinal effectively

Ileal conduit

The isolated segment of small intestine continues to produce mucus (seen in the urine), as part of its normal functioning. The stoma should be dark pink to red and moist. The size of the stoma usually stabilizes within 6 to 8 weeks. Most stomas protrude 0.5 inch to 1 inch (1.25 to 2.5 cm) from the abdominal surface

The nurse is caring for a client who has a history of renal failure. What is an accurate step when caring for the client's hemodialysis access?

The nurse should auscultate over the access site with the bell of the stethoscope, listening for a bruit or vibration, and palpate over the access site, feeling for a thrill or vibration. If these are not present, the health care provider should be notified at once. An IV should not be started in the arm with the access.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

The scanner head should be repositioned, and the bladder should be rescanned before assuming that the bladder is truly empty. Additional ultrasound gel may need to be added for the scanner to work properly The best position for bladder scanning is supine.

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation

A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced?

Total

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

Urinary retention

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. he nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

Wash it with a mild cleanser and water

A client has received nursing teaching about proper skin care at a stomal site. The nurse's teaching has been effective when the client identifies which solution is used to clean the stoma?

Water and mild soap

Which factor is related to developmental changes in bowel habits for older adult clients?

Weakened pelvic muscles lead to constipation.

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

a flexible sheath that is rolled around the penis

The risk for developing colorectal cancer during one's lifetime is 1 in 19. Nurses play an integral role in the promotion of colorectal cancer screening. What are risk factors for colorectal cancer? Select all that apply.

age 50 and older a positive family history a history of inflammatory bowel disease

The BUN test measures the

amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.

A nurse has received an order to insert a urinary catheter into a female client. In preparation, the nurse asks if she has ever had an indwelling catheter and, if so, why and for how long. The nurse has performed which action?

assessed the possibility that the client has urethral strictures

Urge incontinence is caused by

bladder irritation secondary to infection

A reddish-brown urine sample is indicative of the presence of

blood

Digital removal of stool should not be performed on clients who have

bowel inflammation or bowel infection, or after rectal, prostate, and colon surgery.

The large intestine consists of the

cecum, colon (ascending, transverse, descending, and sigmoid), and rectum.

The nurse would suspect the client has decreased bladder contractility, which leads to the

client having issues with urinary retention.

infection may be represented by

cloudy urine

Infection and stasis would cause the urine to appear

cloudy.

The first urine is usually more

concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

The client with advanced liver disease is expected to have

dark brown or dark amber urine

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy

· The normal ostomy stoma should be

dark pink to red and moist. Abnormal findings that should necessitate further assessment of the stoma include paleness (possible anemia), purple-blue color (possible ischemia), bleeding, irritation and dryness, or a yellowish discharge, which could indicate infection.

The urine appears dark amber in color due to

dehydration.

In assessing the bladder, the nurse would first

determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.

The nurse is preparing to place a Foley catheter for a female client who will soon have surgery. Into what position will the nurse place the client?

dorsal recumbent

The appropriate position for a female client who will have a Foley catheter placed is the

dorsal recumbent position

Which is true regarding the normal urination? Catheterized clients should

drain a minimum of 30 mL of urine per hour

The nurse will gather a hypertonic solution to

draw water into the bowel by irritating local tissues.

The small intestine consists of the

duodenum, jejunum, and ileum.

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis?

fecal occult blood test, barium studies, endoscopic examination

The nurse should document the client's condition as stress incontinence

following weakening of perineal and sphincter muscle tone secondary to giving birth.

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?

hypertonic saline

Functional incontinence is caused by

impaired mobility, impaired cognition, or an inability to communicate.

The abdominal assessment should be performed in the following sequence:

inspection, auscultation, percussion, palpation.

The correct sequence for an abdominal assessment is

inspection, then auscultation (done before palpation because palpation may disturb normal peristalsis and bowel motility), followed by percussion and palpation. The client should urinate before assessment and the knees should be flexed with the abdomen during the examination

With a diagnosis of altered body image, a nurse would create

interventions for the client becoming more comfortable with the surgical change.

A 24-hour urine specimen is required for accurate measurement of the

kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day.

Stool produced from an ileostomy is __________ and

liquid : contains large quantities of electrolytes.

Which assessment data, collected by the nurse, indicates that a client may have the nursing diagnosis of urge urinary incontinence? Select all that apply.

loses urine when a toilet is not readily available urinates 20 times in 24 hours experiences accidental loss of urine when there is an urgent need to urinate

Use of an indwelling urinary catheter leads to the

loss of bladder tone.

Mineral oil is used for

lubrication and softening of stool

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere

Abdominal surgery places the client at risk for developing a

paralytic ileus. The nurse would auscultate for bowel sounds, as absent bowel sounds 72 hours after abdominal surgery may signal that the client has developed a paralytic ileus.

Any health problem that involves bleeding of the GI tract, such as

peptic ulcer disease, may require fecal occult blood testing (FOBT).

Vegetables such as cabbage, cucumbers, and onions are commonly known for

producing gas.

Cleansing enemas are used to

relieve constipation or fecal impaction, promote visualization of the intestinal tract by radiographic or instrument examination (colonoscopy), establish regular bowel function, and prevent the involuntary escape of fecal material during surgical procedures.

If the tubing was not clamped before introducing the irrigation solution, the nurse should

repeat the irrigation. If the tubing is not clamped, the irrigation solution will drain into the urinary drainage bag and not enter the catheter

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention?

skin turgor response 5 seconds

An ileal conduit involves a surgical resection of the

small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often

Using the thumb and one finger of the nondominant hand, the nurse should

spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?

strongly aromatic, dark amber

If the stoma is found to be prolapsed,

the surgeon must be notified immediately. The stoma should be pink and remain on the abdominal surface. The mucosal tissue is fragile, so a small amount of bleeding may be normal.

Kegel exercises should be performed by

tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

Bladder irritants such as caffeine can cause

urge incontinence

A straight catheter is a

urine drainage tube inserted but not left in place

A retention (or indwelling) catheter is a

urine drainage tube that is left in place over a period of time.

The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with

vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery