Elimination Coursepoint
A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement?
"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."
A parent brings a 2-year-old child to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states, "I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." Which response by the nurse is appropriate?
"Children vary in their readiness but daytime bowel control may be attained at 30 months."
Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?
"I make sure to limit how much I drink so that I don't have accidents."
A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information?
"I will contract the muscles in my abdomen and thighs."
The nurse is caring for a client who has orders to receive a hypertonic enema. The client asks what is going to happen during the procedure. Which response by the nurse is appropriate?
"I will keep you covered as much as possible during the procedure."
A client reports an episode of losing control of urination when a bathroom was not close by. The client states, "I am worried this means that I am starting to lose control of my bladder." What is the appropriate nursing response?
"Let's review your medication history and whether you consume bladder irritants."
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?"
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 who is planning menus for a client in a long-term care facility takes into consideration the effects of foods and fluids on bowel elimination. Which examples correctly describe these effects? Select all that apply.
-Clients who are constipated should eat more fruits and vegetables. -Clients experiencing flatulence should avoid gas-producing foods such as cauliflower and onions. -Clients with food intolerances may experience altered bowel elimination.
The nurse is assessing a client with a urinary sheath catheter. After removing the catheter, the nurse observes a break in skin integrity on the penis. What actions by the nurse would be appropriate at this time? Select all that apply.
-Do not reapply the urinary sheath -Allow the skin to be open to air as much as possible -Arrange for a consult with a wound nurse
The nurse is assessing a client who reports being constipated. Which assessment data confirm the client report? Select all that apply.
-The client has a distended, hard abdomen. -The client reports fullness in the rectum.
A nurse is assessing the freshly voided urine of a client. What characteristics of the urine would indicate a urinary problem? Select all that apply.
-The urine smells like ammonia -There is pus in the urine. -The urine is cloudy.
An older adult client immigrated to the country and speaks very little of the new country's dominant language. The client reports blood in the stool and is treating it with a mixture of herbs imported from the client's home country. Which statement(s) applies to this client? Select all that apply.
-Treatment for bowel changes with folk remedies is a common practice. -The client may be reluctant to discuss bowel movements in front of a health care provider of the opposite sex.
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 nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.
-black -clay colored -yellow
When caring for a client at the health care facility, the nurse has to record the client's urinary volume. Which amount would indicate a normal urinary volume?
2,000 mL/day
A client has just returned from surgery with a Foley catheter in place. The nurse anticipates that the catheter will be removed within what time frame after the operation?
24 hours
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?
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. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?
An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted.
A nurse inserts a rectal suppository into a middle-age female client. The client says that she has an urge to expel the suppository instantly. Which action should the nurse perform?
Ask the client to contract the gluteal muscles. The nurse should ask the client to contract the gluteal muscles if there is a premature urge to expel the suppository; it helps to tighten the anal sphincters. Asking the client to remain still in a Sims' position will not control the urge to expel but will facilitate access to the rectum. Asking the client to take deep breaths promotes muscle relaxation; it does not help to control the premature urge to expel the suppository. The nurse avoids placing the suppository within the stool because it reduces the effectiveness of the suppository.
The nurse is preparing to do a focused assessment of the abdomen on a client following an abdominal hysterectomy. Which intervention is most important for the nurse to do prior to the physical assessment?
Ask the client to empty her bladder.
The nurse has been closely monitoring a client who has recently had their indwelling urinary catheter removed. In the 6 hours since the catheter was removed, the client has yet to void. How should the nurse first respond to this assessment finding?
Assess the client's bladder by palpation and bedside ultrasound. The nurse should adhere to the nursing process, with assessment preceding interventions (such as reinserting the client's catheter), even if a standing order exists to reinsert the catheter if needed. Similarly, a diuretic would not be the first course of action. A short-term lack of urine output, especially following the removal of a catheter, is not indicative of renal failure.
An older adult client is in the hospital following an intestinal diversion with an ileostomy on the right upper quadrant and a mucous fistula. What is the most important nursing action in the care of this client?
Assess the color of the stoma. A bluish or dark stoma indicates impaired circulation to the stoma. This requires intervention to improve circulation to avoid permanent damage to the stoma. Applying the device would be secondary after the assessment. A stoma irrigation is not a priority in the care of the client. Having the client perform self stoma care would be one of the last interventions provided prior to discharge from the hospital after assessing for readiness.
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 will teach the client to avoid taking more than 250 mg of vitamin C two to three days before testing, and not to consume citrus fruits or juices. Therefore, the other answers are incorrect.
The nurse is caring for a 60-year-old client with an improper bowel movement regimen. Which is the most appropriate method for the nurse to use in teaching this client?
Begin the session with a reference to the client's actual experience.
A nurse is justified in independently identifying and documenting which diagnosis related to impaired elimination?
Bowel Incontinence Bowel incontinence is a NANDA-I-approved nursing diagnosis under the domain of Elimination. Ulcerative colitis, irritable bowel syndrome, and small bowel obstruction are medical diagnoses.
The nurse is teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen?
Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet. The client should first perform hand hygiene, then separate the labia minora and cleanse the perineum with commercially prepared aseptic swabs, starting in front of the urethral meatus and moving the swab toward the rectum. The client should repeat this cleansing process three times with different cotton balls or swabs, then begin to urinate while continuing to hold the labia apart. Next, the client should allow the first urine to flow into the toilet, followed by holding the specimen container under the urine stream. Then, the client should remove the specimen container, release the hand from the labia, seal the container tightly, and finish voiding. The client then performs hand hygiene again.
A student nurse studying human anatomy knows that a structure of the large intestine is the
Cecum The small intestine consists of the duodenum, jejunum, and ileum. The large intestine consists of the cecum, colon (ascending, transverse, descending, and sigmoid), and rectum.
When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?
Check health record for provider's order.
A client could experience increased urination when using which classification of medication?
Cholinergic agents Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination. Analgesics act to relieve pain. Central nervous system depressants are medicines that include sedatives, tranquilizers, and hypnotics. These drugs can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders. Stool softeners makes bowel movements softer and easier to pass.
Then nurse is preparing to apply an external anal pouch. Arrange the following steps in the correct order.
Cleanse entire perianal area and pat dry. Apply skin protectant and allow it to dry. Separate buttocks and apply the pouch to the anal area. Attach the pouch to a collection drainage bag. Hang the drainage bag below the client.
An older adult client with Parkinson disease is unable to take perform self-care activities. The client frequently soils the bed and is unable to clean themselves independently. How should the nurse in this case ensure the client's perineal care?
Cleanse to remove secretions from less soiled to more soiled areas.
A client with food poisoning has the nursing diagnosis "diarrhea." Which expected client outcome most directly demonstrates resolution of the problem?
Client will have formed stools within 24 hours.
During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care?
Condom Catheter A condom catheter may be used in the care of male clients who lack voluntary control of urination. This is preferable to invasive catheterization (which presents an infection risk). Frequent toileting such as every 2 hours may prevent episodes of incontinence but would significantly disrupt the client's sleep quality.
A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?
Contact the health care provider The term pyuria refers to the presence of pus in the urine. The nurse should first contact the health care provider, as antibiotic therapy may be necessary. Encouraging fluids, instruction on wiping technique and monitoring vital signs will follow.
The UAP reports that a client on furosemide has voided 4000 mL in a 24-hour period. What is the appropriate nursing action?
Contact the health care provider to decrease furosemide.
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. Corn is high in cellulose, which is an insoluble fiber that the body cannot digest. However, the body breaks down the other components of corn. Chewing corn for longer can also help the digestive system break down cellulose walls to access more of the nutrients. Sucrose, lactose, and galactose are sugars that are not fiber and more easily digestible by the body. During digestion, starches and sugars are broken down both mechanically (e.g. through chewing) and chemically (e.g. by enzymes) into the single units glucose, fructose, and/or galactose, which are absorbed into the blood stream and transported for use as energy throughout the body.
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. The procedure may stimulate a vagal response, which increases parasympathetic stimulation. The nurse does use digital removal as a last resort. It is an uncomfortable but necessary procedure for the client. Because clients are uncomfortable with fecal impaction, the client will consent for the procedure. Digital removal does not cause rebound diarrhea nor electrolyte loss.
A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next?
Document this normal finding for postvoid residual.
A home care client has an indwelling catheter connected to a leg bag. What can the nurse recommend to help prevent development of a urinary tract infection?
Empty the leg bag at regular intervals. Clients with indwelling catheters are at risk for the development of a urinary tract infection. A full drainage bag may cause reflux of urine into the bladder, increasing the risk of a urinary tract infection.
A client is prescribed an indwelling urinary catheter for 2 days prior to surgery. Which action should the nurse take to decrease the occurrence of health care-associated infection (HAI) for this client?
Encourage fluid intake. Urinary catheterization is the most common cause of HAI. The catheter should be inserted for the shortest possible duration. Fluids should be encouraged. Intermittent catherization and too frequent catheter irrigation can increase the risk of infection.
The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure?
Ensure that the client fasts 6 to 12 hours before the test as per policy.
A hospitalized client has become constipated in recent days, in spite of maintaining a high fluid intake and taking oral stool softeners. The client reports feeling mortified to attempt a bowel movement on a commode at the bedside, where staff and other clients can hear. The nurse should respond by modifying which resource?
Environment
An older adult client has been receiving care in a two-bed room that he has shared with another older, male client for the past several days. Two days ago, the client's roommate developed diarrhea that was characteristic of Clostridioides difficile. This morning, the client himself was awakened early by similar diarrhea. The client may have developed which type of infection?
Exogenous healthcare-associated The client's suspected infection originated with another person (exogenous) and was contracted in the hospital (healthcare-associated). It was not the result of his treatment (iatrogenic) and Clostridioides difficile is not an antibiotic-resistant microorganism. Endogenous infections originate from within the organism and are not attributed to an external or environmental factor.
A client who is postoperative Day 1 has rung the call light twice during the nurse's shift in order to request assistance transferring to a bedside commode. In both cases, however, the client has been unable to defecate. In light of the fact that the client's last bowel movement was the morning of surgery, what action should the nurse first take?
Facilitate a more private setting, such as assisting the client to a bathroom.
"Vagal response" is the voluntary increase of intra-abdominal pressure that helps expel feces.
False A vagal response, is an involuntary response which increases parasympathetic stimulation, causing a decrease in heart rate. This can occur with administration of an enema. A nurse should assess the client while administration of an enema.
Urinary elimination from an ileal conduit can be voluntarily controlled after the stoma heals from the initial surgery.
False An ileal conduit is a cutaneous urinary diversion that involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of the small bowel. This separated section of the small intestine is then brought to the abdominal wall, where urine is excreted through a stoma. Such diversions are usually permanent, and the client wears an external appliance to collect the urine, since elimination of the urine from the stoma cannot be controlled voluntarily.
A nurse is scheduling diagnostic studies for a client. Which test would be performed first?
Fecal occult blood test
A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence?
Functional The nurse should document the client's condition as functional incontinence when the client is unable to retain urine for some time after getting an urge to void.
The nurse is preparing to administer an enema to a client who is constipated. Upon assessment, the nurse notes painful distended veins on the exterior rectum. Which action will the nurse take next?
Generously lubricate the enema tube tip before proceeding. Abnormal distention of the veins in the rectum results in the formation of hemorrhoids. Hemorrhoids may be a contributor to constipation if the individual ignores the urge to defecate. Hemorrhoids can tear due to the firm enema tip; therefore, the enema tip should be generously lubricated and administered with caution to avoid tearing. Continuing as usual is inappropriate due to the hemorrhoid finding. Nurses do not digitally stimulate a client to void. The decision to change the enema solution is a health care provider order; therefore, the nurse cannot perform this option without speaking with the provider first.
Which is an actual nursing diagnosis?
Impaired urinary elimination
A nurse is assessing a client with constipation and severe rectal pain. Which action should the nurse perform to determine the presence of fecal impaction?
Insert a lubricated, gloved finger into the rectum. The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it.
A client is scheduled for liposuction surgery to reduce weight. Which action should the nurse take immediately after surgery?
Listen to bowel sounds
The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse's next action?
Lower solution container and check temperature and flow rate. The nurse's next action would be to lower the solution container and check the temperature and flow rate. Lowering the solution container decreases the pressure of the flow of the solution. The cramping could be related to the pressure of the flow, the temperature of the solution, or a high flow rate of the solution. The nurse would not place the client in a supine position, but in a low-Fowler's position or higher. The nurse would not remove the tube and check for any fecal contents. The nurse would not modify the amount and length of the administration, as this is not causing the severe cramping.
A nurse is providing care to a client who has undergone a colonoscopy. What would be most appropriate for the nurse to do after the procedure?
Monitor for rectal bleeding.
The nurse is preparing to perform perineal care on an uncircumcised adult male client who was incontinent of stool. The client's entire perineal area is heavily soiled. Which technique for cleaning the penis is correct?
Retract the foreskin while washing the penis, and then immediately pull the foreskin back into place.
The nurse is teaching a client how to change an ostomy appliance. After removing the existing pouch, which action will the nurse teach next?
Shower, bathe, or wash peristomal area with mild soapy water.
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.
Which is not true of urine color?
The appearance of urine streaked with blood is always abnormal.
The nurse is providing education to a client who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the client?
The catheter can be connected to a smaller leg bag for ambulation.
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 client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem?
The position does not facilitate downward pressure. Most people assume the squatting or slightly forward-sitting position with the thighs flexed to defecate. These positions result in increased pressure on the abdomen and downward pressure on the rectum to facilitate defecation. Obtaining the same results when seated on a bedpan is difficult.
Use of an indwelling urinary catheter leads to the loss of bladder tone.
True People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.
The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice?
Urinal
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. Washing the stoma and surrounding skin with a mild cleanser and water and patting it dry can preserve skin integrity. When using a cleanser, it is important to rinse the area thoroughly. Any residue left on the skin can cause problems with the wafer adhering. Another way to protect the skin is to apply barrier substances such as karaya, a plant substance that becomes gelatinous when moistened, and commercial skin preparations around the stoma. Cleaning the stoma with just a dry, cotton bandage is not the correct way of preserving skin integrity.
During a visit to the pediatrician's office, a parent inquires about toilet training the 2-year-old child. Which toilet training readiness factor should the nurse include in teaching the parent about toilet training?
When your child can recognize bladder fullness. Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for 2 hours, recognizes the feeling of bladder fullness, communicates the need to void, and controls urination until seated on the toilet.
The nurse should recognize the possibility of maintaining a continuous bladder irrigation system when admitting:
a client who has undergone prostate resection surgery that morning. The purpose of continuous bladder irrigation is to prevent catheter blockage, usually by a blood clot. Consequently, recent urological surgery may necessitate such a measure. Incontinence does not create a need for intermittent or continuous bladder irrigation. A woman who has given birth is similarly unlikely to require continuous irrigation of her bladder and urethra.
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
The nurse writes a a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client?
acute kidney injury Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive acute kidney failure. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.
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
When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate?
briefly clamping the tubing while the client breathes deeply Some clients experience cramping when receiving a cleansing enema. The nurse will clamp the tube for a brief period while the client takes deep breaths, and then resume the infusion. A slower infusion rate may be necessary. Other choices are incorrect.
A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema?
cleansing enema The most common types of solutions used for cleansing enemas are tap water, normal saline, soap solution, and hypertonic solution. 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. Carminative enemas are classified as retention enemas and are used to expel flatus from the rectum and provide relief from gaseous distention. Return-flow enemas are also occasionally prescribed to expel flatus.
A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?
decreased fluid volume risk
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?
dehydration
A nurse is caring for a client who is being treated for bladder infection. The client reports having difficulty voiding and feeling uncomfortable. How should the nurse document the client's condition?
dysuria
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?
hypertonic saline
A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding?
increased bowel sounds
The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing:
oliguria Oliguria is a significant decrease in urine production.
The nurse is administering a rectal suppository. How far will the nurse insert the suppository?
past the internal sphincter
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?
predisposition to renal calculi In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.
The health care provider prescribes a large-volume cleansing enema for a client. What outcome does the nurse identify that will be optimal for this client?
removes hardened fecal impactions from the rectum
What is the most common type of colostomy that needs to be irrigated to help promote regular evacuation of feces?
sigmoid colostomy Irrigations are infrequently used to promote regular evacuation of some colostomies. Various factors, such as the site of the colostomy in the colon (preferably the sigmoid colostomy where constipation occurs) and the client's and health care provider's preferences, determine whether a colostomy is to be irrigated. Ileostomies are not irrigated because the fecal content of the ileum is liquid and cannot be controlled. The transverse and ascending colon are located before the sigmoid area, which is closest to the rectum.
A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use?
straight catheter The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time.
A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate?
stress Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.
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
A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?
suprapubic catheter A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra. An indwelling urethral catheter, straight, and intermittent urethral catheter is placed in the urethra.
When preparing to administer a large cleansing enema to a client, which solution does the nurse gather?
tap water The nurse will gather tap water, which is used to distend the rectum and moisten stool. Mineral oil is used for a retention enema. Soap and water are used to irritate local tissue; hypertonic saline irritates local tissue and draws water into the bowel.
A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called?
urinary incontinence The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence. Urge incontinence is uncontrolled urine leakage or voiding (of moderate to large volume) that occurs immediately after an urgent, irrepressible need to void.
A nurse from the ambulatory surgical center is preparing discharge instructions for a client who has had pelvic surgery. Which criterion would the client need to demonstrate to ensure that she is ready for discharge?
void normally
Which action taken by the nurse while collecting a stool sample has the greatest impact on minimizing risk?
wearing disposable gloves
A client has been admitted to the hospital with a diagnosis of acute kidney injury, a health problem that necessitates vigilant monitoring of the client's fluid balance. What is the most accurate way that the care team can achieve this assessment goal?
weighing the client once per day Because of variations and potential oversights in the monitoring of clients' intake and output, daily weights are considered one of the more accurate measures of fluid balance. Skin turgor is not a reliable assessment in isolation. Daily laboratory studies may reveal the physiologic causes and consequences of fluid imbalance, but they do not gauge the problem itself. Similarly, the measurement of urine volume and concentration will likely be confounded by the client's diagnosis of renal failure, though each would certainly be monitored. Output is not meaningful data without considering fluid intake.
A nurse is assessing the stools of a breastfed infant. What is the appearance of normal stools for this infant?
yellow, loose, odorless
