Elimination
A client who had a cesarean birth is unable to void 3 hours after the removal of an indwelling catheter. How can the nurse evaluate whether the client's bladder is distended? By catheterizing the client for residual urine By palpating the client's suprapubic area gently By asking the client whether she still feels the urge to urinate By determining whether the client is experiencing suprapubic pain
By palpating the client's suprapubic area gently Palpation will indicate whether is present. The increased intra-abdominal space available after birth can result in bladder distention without discomfort. Assessment should be done first. Trauma to the area makes surrounding organs atonic; the client may have a full bladder and not feel the urge to void.
After several episodes of abdominal pain and vomiting, a 5-month-old infant is admitted with a tentative diagnosis of intussusception. What observation should the nurse document that will aid confirmation of the diagnosis? Frequency of crying Amount of oral intake Characteristics of stools Absence of bowel sounds
Characteristics of stools Because intussusception creates intestinal obstruction in which the intestine "telescopes" and becomes trapped, passage of intestinal contents is lessened; stools are red and look like currant jelly because of the mixing of stool with blood and mucus. Frequency of crying is a behavior is not specific to a diagnosis of intussusception. Accurate intake and output records are important, but they are not essential for confirming this diagnosis. Bowel sounds will not be affected significantly with intussusception.
A nurse is assessing the urine of a client with a urinary tract infection. What appearance should the nurse expect this client's urine to have? Smoky Cloudy Orange-amber Yellow-brown
Cloudy Cellular debris, white blood cells, bacteria, and pus can cause the urine to become cloudy. Dark, smoky urine usually suggests hematuria. Orange-amber color of urine may indicate concentrated urine; also, it can be caused by phenazopyridine (Pyridium) or foods such as beets. Yellow-brown to olive green color of urine indicates excessive bilirubin.
How should the nurse expect the urine of a child with acute glomerulonephritis with hematuria to appear? Cola-colored Orange Bright red Straw-colored
Cola-colored Cola-colored urine indicates the presence of large numbers of red blood cells. Orange-colored urine usually is associated with certain foods or medications. Red indicates frank bleeding that is associated with urinary tract trauma, not glomerulonephritis. Straw-colored urine is the color of dilute urine; it is an expected finding in a healthy child.
A client who had a lithotripsy for a renal calculus is to be discharged from the hospital. What should the nurse include in the home care instructions? Drink at least 3 L of fluid daily for four weeks Eliminate organ meats from the diet for six weeks Increase the intake of dairy products for five days Restrict movement for three days before resuming usual activities
Drink at least 3 L of fluid daily for four weeks Increasing fluid intake aids in the passage of fragments of the calculus that remain after the lithotripsy. Organ meats are high in purine, an amino acid, which is a causative factor in the formation of uric acid crystals; they should be avoided by people with gout. Calcium is the major component of the most common type of calculus; the intake of dairy products, which are high in calcium, should be limited. Early ambulation is encouraged to aid in the passage of fragments of the calculus that remain after a lithotripsy.
A client is scheduled for a colonoscopy, and the health care provider prescribes a tap water enema. In which position should the nurse place the client during the enema? Left Sims Back lying Knee chest Mid-Fowler
Left Sims To take advantage of the anatomical position of the sigmoid colon and the effect of gravity, the client should be placed in the left Sims or left side-lying position for the enema. Back lying, knee chest, or mid-Fowler positions do not facilitate the flow of fluid into the sigmoid colon by gravity.
The diet prescribed for a client with diverticulosis includes 30 grams of fiber a day. What breakfast items should the nurse encourage the client to select? Cream of wheat, milk, and cranberry juice Unstrained orange juice, pancakes, and bacon Oatmeal, sliced bananas, whole-wheat toast, and milk Poached eggs on whole-wheat toast, tomato juice, and tea
Oatmeal, sliced bananas, whole-wheat toast, and milk A breakfast including oatmeal, sliced bananas, whole-wheat toast, and milk contains grains and fruit that are high in fiber and helps meet the 30-gram daily requirement of fiber. Cream of wheat, milk, and cranberry juice are not high in fiber; they do not help meet the 30-gram daily requirement of fiber. Unstrained orange juice, pancakes, and bacon are low-fiber foods; they do not help meet the 30-gram daily requirement of fiber. Although whole grain bread is a high-fiber food and tomato juice contains some fiber, this grouping does not have as much fiber as another breakfast choice.
A nurse obtains daily stool specimens for a client with chronic bowel inflammation. The nurse concludes that these stool examinations were prescribed to determine: Fat content. Occult blood. Ova and parasites. Culture and sensitivity.
Occult blood. Occult blood in the stool may indicate active bleeding. Fat content does not warrant examining the stool for fat. There is no indication that parasites are present; the situation does not warrant examining the stool for an infestation. Culture and sensitivity does not warrant culturing the stool for bacteria.
A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? Incisional pain Absent bowel sounds Urine output of 20 mL/hour Serosanguineous drainage on the dressing
Urine output of 20 mL/hour A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon.
A mother tells the clinic nurse that her 6-year-old child has been wetting the bed for the past 3 weeks. Previously there had been no problems. How should the nurse respond? "Try to eliminate fluids after dinner." "Children sometimes wet the bed when they're angry." "You did the right thing to bring your child in to be examined." "Wake your child every few hours at night to go to the bathroom."
"You did the right thing to bring your child in to be examined." This child, who is older than 5 years, had control of the bladder until 3 weeks ago; the first step in evaluating enuresis is to rule out any physical problems that may be causing it. Suggesting interventions for the problem is inappropriate until the cause of the problem is identified. Stating that children wet the bed when they are angry is inappropriate because it implies that this is a voluntary act. Waking the child every few hours will interfere with the child's rest; advice is inappropriate until the cause of the problem is identified.
A pregnant client complains of constipation. Which strategies should the nurse recommend? Exercise regularly. Take a mild laxative before breakfast. Drink at least one caffeinated beverage daily. Add a few tablespoons of wheat bran to cereal at breakfast. Plan to have a bowel movement at the same time every day.
#1,4 and 5 One of the benefits of regular exercise is that it promotes peristalsis. High fiber foods promote peristalsis. Setting aside a specific time of day helps establish regular bowel habits. Medications should not be recommended or taken during pregnancy without a prescription. Caffeinated beverages do not relieve constipation and may be harmful. Staying hydrated by drinking 8 to 10 glasses of fluid per day may relieve the constipation. Water, milk, and fruit juices are recommended.
A hospitalized client is scheduled to have a sigmoidoscopy. The nurse anticipates that pre-procedure prescriptions will include: Providing instructions about restraints used during the procedure. Administering a fleet enema 1 hour before the procedure. Encouraging increased intake of clear fluids. Administering morphine 30 minutes before the procedure.
Administering a fleet enema 1 hour before the procedure. 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. The client will be kept NPO for at least 8 hours before the procedure. Morphine is not typically used as a pre-op medication before a sigmoidoscopy. Restraints are not typically used during the procedure.
A client is diagnosed with a peptic ulcer. When teaching about peptic ulcers, the nurse instructs the client to report any stools that appear: Frothy Ribbon shaped Pale or clay colored Dark brown or black
Dark brown or black Dark brown or black stools (melena) indicate gastrointestinal bleeding. Frothy stools are indicative of inadequate fat absorption and are associated with sprue. Ribbon-shaped stools indicate a bowel mass or obstruction. Clay-colored stools usually are related to problems that cause a decrease in bile.
A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this client's plan of care? Ensuring a large fluid intake Providing a high-calcium diet Instituting seizure precautions Encouraging complete bed rest
Ensuring a large fluid intake Fluids help prevent the formation of renal calculi associated with high levels of serum calcium. Additional calcium intake may increase the already high levels of serum calcium. Seizures are associated with low, not high, levels of serum calcium. Bed rest is contraindicated because it accelerates bone destruction.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? Low in fat High in iron High in fluids Low in residue
High in fluids A common side effect of vincristine is a paralytic ileus, which results in constipation. Preventative measures include high fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.
A nurse is reviewing the laboratory report of an adolescent child with nephrotic syndrome. What does the nurse expect analysis of the child's urine to reveal? High protein level Low specific gravity Numerous red blood cells Several crystalline particles
High protein level Protein (albumin) is present in the urine of children with nephrotic syndrome; it is evidence of kidney damage. Proteinuria, combined with oliguria, results in an increased urine specific gravity. Only rarely do red blood cells (RBCs) or RBC casts filter through the glomerular basement membrane. Crystals are not found in the urine of children with nephrotic syndrome.
A nurse is caring for a client who is scheduled for cystoscopy. What should the nurse include in the client's postprocedure teaching plan? Remain flat in bed for the first 24 hours Increase fluid intake for three to four days postoperatively Notify the nurse if there is any drainage on the dressing Bear down when attempting to void during the first six hours
Increase fluid intake for three to four days postoperatively Increasing fluid intake flushes the bladder internally and helps decrease the risk of infection. Remaining flat in bed for the first 24 hours is unnecessary after a cystoscopy. A cystoscopy is performed through the urethra; a dressing is not necessary. Bearing down increases pressure in the pelvic and perineal area and should be avoided.
A client has been diagnosed with cholelithiasis. Which fact about cholelithiasis should the nurse recall when assessing this client for risk factors? Men are more likely to be affected than women. Young people are affected more frequently than older people. Individuals who are obese are more prone to this condition than those who are thin. People who are physically active are more apt to develop this condition than those who are sedentary.
Individuals who are obese are more prone to this condition than those who are thin. Cholelithiasis occurs more frequently in individuals who are obese and have hyperlipidemia. In the United States, more women than men have a calculus of the gallbladder by 65 years of age. Older people, usually ≥60 years, are more likely to develop this condition than younger people. People who have sedentary lifestyles are more likely to develop this condition than those who are active.
A nurse is preparing to administer an oil-retention enema and understands that it works primarily by: Stimulating the urge to defecate. Lubricating the sigmoid colon and rectum. Dissolving the feces. Softening the feces.
Lubricating the sigmoid colon and rectum. The primary purpose of an oil-retention enema is to lubricate the sigmoid colon and rectum. Secondary benefits of an oil-retention enema include stimulating the urge to defecate and softening feces. An oil-retention enema does not dissolve feces
A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the health care provider. What should the nurse do to help prevent the client from developing a urinary tract infection? Assess urine specific gravity Maintain the prescribed hydration Collect a weekly urine specimen Empty the drainage bag frequently
Maintain the prescribed hydration Promoting hydration maintains urine production that flushes the bladder, thereby preventing urinary stasis and possible infection. Although assessing urine specific gravity may help identify a urinary tract infection, it will not prevent it. Although collecting a weekly urine specimen for culture and sensitivity may help identify a urinary tract infection, it will not prevent it. The collection bag is emptied once every shift unless the bag is full and needs to be emptied sooner; changing the bag periodically, not emptying it, may help prevent infection.
A nurse is caring for an older bedridden male client who is incontinent of urine. What nursing intervention is the most satisfactory initial approach to managing urinary incontinence? Restricting fluid intake Offering the urinal regularly Applying incontinence pants Inserting an indwelling urinary catheter
Offering the urinal regularly Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence; also it promotes skin breakdown and can lower self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection, promotes an atonic bladder, and prolongs incontinence. Also, it requires a health care provider's prescription.
The health care provider prescribes mebendazole (Vermox) for a 4-year-old child with pinworms. For which expected response to the medication does the nurse teach the parents to be alert? Blood Constipation Yellow stools Passage of worms
Passage of worms Passage of worms is the expected response because the medication causes the death of the worms. Neither the drug nor the worms cause intestinal bleeding. Transient diarrhea, not constipation, may occur. The medication may color the stool red, not yellow.
What is the most basic method the nurse can use when encouraging hospitalized clients to void? Providing privacy Warming a bedpan Having the client listen to running water Placing the client's hands in warm water
Providing privacy A strange environment, as well as the anxiety associated with private body functions like elimination, may interfere with the client's ability to relax the urinary sphincter to void. Warming a bedpan might be helpful in some situations; however, it does not take into account the common anxiety of voiding in a strange environment. Having the client listen to running water might be helpful in some situations; however, it does not take into account the common anxiety of voiding in a strange environment. Placing the client's hands in warm water might be helpful in some situations; however, it does not take into account the common anxiety of voiding in a strange environment.
A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for? Sweat test Guthrie test Rectal biopsy Blood glucose level
Rectal biopsy During a rectal biopsy a specimen is obtained and examined for the absence of ganglion cells. Hirschsprung disease is also known as congenital aganglionic megacolon. A sweat test is performed to determine the presence of cystic fibrosis. The Guthrie test is performed on a neonate to determine the presence of inborn errors of metabolism. The blood glucose level is unrelated to the diagnosis of Hirschsprung disease.
A client who is suspected of having salmonellosis asks the nurse how the diagnosis is confirmed. The nurse responds that the medical diagnosis is established by a: Urinalysis Stool culture Febrile agglutinin test Complete blood count
Stool culture The Salmonella bacilli can be visualized via microscopic examination of stool. Although a urinalysis might be done, it is not definitive for the diagnosis of salmonellosis. Although a febrile agglutinin test might be done, it is not definitive for the diagnosis of salmonellosis. Although a complete blood count might be done, it is not definitive for the diagnosis of salmonellosis.
