Elimination- PrepU
A 2-month-old infant is at risk for an ileus after surgery to correct intussusception. What should be included in a focused assessment for this complication? Select all that apply. a) measurement of gastric output b) assessment of bowel sounds c) measurement of urine specific gravity d) characteristics of the first stool e) bilirubin levels
A, B, D
The nurse is planning care for an obese female client. The client experiences dribbling urine when she coughs, sneezes, and changes positions. The nurse should instruct the client to promote urinary health by encouraging which actions? Select all that apply. a) Use adult diapers as needed. b) Participate in a weight loss program. c) Increase consumption of fluids such as coffee and tea. d) Perform muscle-strengthening exercises (Kegel exercises). e) Use a Foley catheter.
A, B, D
When teaching the client with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the client to report which symptoms to the health care provider (HCP)? Select all that apply. a) blood in the urine b) fever above 100° F (37.8° C) c) cloudy urine for the first few days d) mild nausea e) urinating every 3 to 4 hours f) rash
A, B, F
What should the nurse do to prevent catheter associated urinary tract infection (CAUTI)? Select all that apply. a) Recommend the health care provider (HCP) prescribe antibiotics. b) Monitor the temperature as an indicator of the infection. c) Change the catheter daily. d) Provide perineal care several times a day. e) Encourage the client to drink 3,000 mL of fluids a day
B, D, E
A nurse is teaching the parents of a child diagnosed with a UTI secondary to vesicourethral reflux. How should the nurse explain how the reflux contribute to the infection? a) "It prevents complete emptying of the bladder." b) "It causes urine back flow into the kidney." c) "It results in painful bladder spasms." d) "It causes painful urination."
a) "It prevents complete emptying of the bladder."
A recent history of which of the following should alert the nurse to gather additional information about the possibility of a urinary tract infection in a 2-year-old child who is exhibiting fever and fussiness? a) abdominal pain b) swollen lymph nodes c) skin rash d) back pain
a) abdominal pain
A female client is experiencing bladder control problems. Which outcome indicates the success of nursing interventions to promote urinary continence for this client? a) continence for 24 hours a day b) compliance with drinking and voiding schedule c) self-monitoring for urine retention d) improvement in bladder control
a) continence for 24 hours a day
To reduce the possibility of catheter-related urinary tract infections (CAUTIs), the nurse should: a) minimize urinary catheter use and duration of use in all clients. b) use sterile technique when providing catheter care. c) clean the periurethral area with antiseptics. d) ensure that clients who are incontinent have indwelling urinary catheters
a) minimize catheter use and duration of use in all clients
Which measure included in the care plan for a client in the fourth stage of labor requires revision? a) Obtain an order for catheterization to protect the bladder from trauma. b) Check vital signs and fundal checks every 15 minutes. c) Perform perineal assessments for swelling and bleeding. d) Have the client spend time with the neonate to initiate breast-feeding
a) obtain an order for cauterization to protect the ladder from trauma
A father of a child with a UTI cals the clinic and explains, "My wife and I are concerned because out child refuses to obey uses concerning the preventions you told us about. Our child refuses to take the medication unless we but a present. We don't want to use discipline because of the illness, but we are worried about the behavior." Which response by the nurse is best? a) "I sympathize with your difficulties, but just ignore the behavior for now." b) "I understand its hard to discipline a child who is ill, but things need to be kept as normal as possible." c) "I understand that things are difficult for you right now, but your child is ill and deserves special treatment." d) " I understand your concern, but this type of behavior happens all the time; your child will get over it when feeling better."
b) "I understand its hard to discipline a child who is ill, but things need to be kept as normal as possible."
The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following topics would be important for the nurse to include in the teaching plan? a) Increased peripheral vascular resistance. b) Increased risk for urinary tract infections. c) Decreased plasma volume. d) Increased hemoglobin levels.
b) increased risk for urinary tract infections
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing sever diarrhea? a) monitoring the total 8-hour formula intake b) weighing the infant each day c) checking the anterior fontanel every shift d) monitoring abdominal skin turgor every shift
b) weighing the infant each day
Which urine output indicates that a 5-month-old weighing 15 lb (6.8 kg) and being treated for dehydration has a normal urine output? a) 6 to 8 mL/kg/h b) 3 to 5 mL/kg/h c) 1 to 2 mL/kg/h d) 10 to 12 mL/kg/h
c) 1 to 2 mL/kg/h
A client has urge incontinence. When obtaining the health history, the nurse should ask if the client has: a) inability to empty the bladder. b) frequent dribbling of urine. c) involuntary urination with minimal warning. d) loss of urine when coughing
c) involuntary urination with minimal warning
A health care provider and nurse are discussing treatment options with a client diagnosed with severe ulcerative colitis. When providing client teaching during early treatment, the symptoms of which diagnosis would be discussed? a) Bowel herniation b) Bowel out pouching c) Gastritis d) Bowel perforation
d) bowel perforation
A postpartum client has a nursing diagnosis of risk for impaired urinary elimination related to loss of bladder sensation after childbirth. Which of the following priorities outcome criteria should the client achieve? a) The client will void a sufficient amount of clear yellow urine 4 hours after birth. b) The client will drink 6 to 8 glasses of fluids in a 24-hour period of time. c) The client will state that she has no discomfort with urinary elimination. d) Client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth
d) client voids more than 30 mL/hour without urinary retention beginning 1 hour after birth
Which of the following would be an important assessment finding for an 8-month-old infant admitted with sever diarrhea? a) bowel sounds every 5 seconds b) pale yellow urine c) normal skin elasticity d) depressed anterior fontanel
d) depressed anterior fontanel
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is not appropriate? a) setting a regular time for elimination b) eating a diet high in fiber c) using an elevated toilet seat d) limiting fluid intake to 1,000 mL/day
d) limiting fluid intake to 1,000 mL/day
A 9-month-old is admitted because of dehydration. How should the nurse go about accurately monitoring fluid intake and output. Select all that apply. a) weighing and recording all wet diapers b) change breast feeding to bottle feeding c) obtaining an accurate daily weight d) restricting fluids prior to weight the child e) obtaining an accurate stool count
A, C, E
An older adult who is to be on bed rest has become incontinent of urine. To prevent pressure ulcers, the nurse should do which tasks? Select all that apply. a) Inspect the groin for wetness. b) Use a sanitary napkin to absorb urine. c) Have client wear incontinence briefs. d) Anchor a Foley catheter. e) Institute a turning schedule.
A, C, E
A client who is experiencing colon cancer is scheduled to undergo a colostomy. Which interventions would be appropriate to include in a preoperative teaching plan? Select all that apply. a) Instruct on dietary guidelines for healing. b) Demonstrate turning, coughing, deep breathing, splinting, and leg ROM exercises, and provide rationales for each procedure. c) Arrange for an ET to speak with the client about colostomy care. d) Instruct the client on signs and symptoms of intestinal obstruction. e) Encourage the client to express feelings about changes in body image. f) Explain the need for early postoperative ambulation
B, C, E, F
A client with constipation is prescribed an irrigating enema. Which steps should the nurse take when administering an enema? Select all that apply. a) Warm the solution to 110°F (43.3°C). b) Lubricate the distal end of the rectal catheter. c) Insert the tube 1 to 1 1/2 inches (2.5 to 3.75 cm). d) Administer 250 to 500 mL of irrigating solution. e) Assist the client into the left-lateral Sims' position. f) Be sure to keep the solution container below 18 inches (45 cm) above bed level
B, E, F
The nurse is teaching the parents of a young child who had surgery to form a colostomy what to expect when the child goes home. The parents express concern about the appearance of the stoma. Which of the following is the most appropriate response by the nurse? a) "The size of the new stoma should stabilize in 6-8 weeks." b) "The stoma will change to a flesh color after three months." c) "You can use a skin barrier to cover the appearance of the stoma." d) "Children have a difficult time accepting a stoma."
a) "The size of the new stoma should stabilize in 6-8 weeks."
A nurse is taking a health history of a 10-year-child and discovers that the child has difficulties in urinary control during the day. The parents are confused about the condition and ask the nurse for help. What is the most appropriate response by the nurse? a) "There may be a significant stressor in your child's life that's causing this." b) "Your child must be forgetting to go to the bathroom during the day." c) "You need to provide suitable undergarments to prevent embarrassment." d) "Lack of urinary control during the day is indicative of a urinary tract infection."
a) "There may be a significant stressor in your child's life that's causing this."
When caring for a client who has recently given birth, the nurse assesses the client for urinary retention with overflow. Which sign or symptom provides the most accurate picture of retention with overflow? a) A varying urge to urinate with an average output of 100 ml b) Uterus displaced to the right with increased vaginal bleeding c) Frequent trips to the bathroom with an average output of 200 to 300 ml per void d) Intense urge to urinate with an average output of 250 ml
a) a varying urge to urinate with an average output of 100 ml
An 8-year-old child is admitted with a T3 spinal cord compression following a motor vehicle accident. The child has an abrupt onset of elevated blood pressure, headache, profuse sweating, and flushing of the skin. Which of the following is the priority action for the nurse to take? a) Empty the child's bladder. b) Administer a fluid bolus. c) Obtain a blood glucose level. d) Place the child in a supine position.
a) empty the child's bladder
Which nursing action is most appropriate for a client who has urge incontinence? a) Have the client urinate on a timed schedule. b) Provide a bedside commode. c) Teach the client intermittent self-catheterization technique. d) Administer prophylactic antibiotics.
a) have the client urinate on a timed schedule
In the fourth stage of labor, a full bladder increases the risk of what postpartum complication? a) Hemorrhage b) Disseminated intravascular coagulation (DIC) c) Infection d) Shock
a) hemorrhage
After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal? a) keeps the new urethra from closing b) measures his urine correctly c) prevents bladder spasms d) decreases pain at the surgical site
a) keeps the new urethra from closing
A client with colon cancer is having a barium enema. The nurse should instruct the client to take which type of medication after the procedure is completed? a) laxative b) demulcent c) anticholinergic d) antacid
a) laxative
A client has been diagnosed with an intestinal obstruction and has a nasogastric tube set to low continuous suction. Which acid-base disturbance is this client at risk for developing? a) Metabolic alkalosis b) Metabolic acidosis c) Respiratory alkalosis d) Respiratory acidosis
a) metabolic alkalosis
A client with chronic bowel inflammation reports abdominal cramping and diarrhea for the past 4 days. The nurse would anticipate which of the following tests based on the client's concerns? a) Occult blood and organisms b) Culture and sensitivity c) Fat and undigested food d) Ova and parasites
a) occult blood and organisms
Which of the following would be the most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with sever diarrhea to help her comfort her infant who is fussy? a) offering a pacifier b) placing a mobile above the crib c) sitting at crib side talking to the infant d) turning the television on to cartoons
a) offering a pacifier
When emptying the client's bladder during a urinary catheterization, the nurse should allow the urine to drain from the bladder slowly to prevent: a) possible shock. b) renal failure. c) abdominal cramping. d) atrophy of bladder musculature.
a) possible shock
After undergoing a barium enema, which finding indicates that the infant has adequately evacuated the barium? a) stools that progress from clay-colored to brown b) bowel sounds of 30 per minute c) absence of fecal mass in the lower abdomen d) stool guaiac that is negative
a) stools that progress from clay-colored to brown
The parents of an infant with a colostomy are concerned that their child's colostomy bag is filling up frequently with gas. What is the most appropriate response by the nurse? a) "Don't worry. This is a normal occurrence." b) "Open the bag slightly whenever this happens." c) "Restrict the intake of bottled formula." d) "Place a few pin pricks in the bag.
b) "open the bag slightly whenever this happens"
A nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? a) Consulting with a dietitian b) Encouraging intake of at least 2 L of fluid daily c) Taking the client to the bathroom twice per day d) Giving the client a glass of soda before bedtime
b) encouraging intake of at least 2L of fluid daily
The nurse is caring for a client with severe diarrhea. The nurse recognizes that the client is at risk for developing which of the following acid-base imbalances? a) Respiratory alkalosis b) Metabolic acidosis c) Metabolic alkalosis d) Respiratory acidosis
b) metabolic acidosis
A nurse is caring for a child with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Monitor vital signs every 4 hours. b) Monitor the appearance, size, and number of stools. c) Measure intake and output. d) Measure blood urea nitrogen and serum creatinine levels
b) monitor the appearance, size, and number of stools
Which initial manifestation of acute renal failure is the most common? a) hematuria b) oliguria c) dysuria d) anuria
b) oliguria
The nurse is caring for a 9-month-old child with severe diarrhea that has lasted 3 days. Which of the following would be a priority assessment for the nurse to make? a) Hyponatremia b) Poor skin turgor c) Jaundice d) Anemia
b) poor skin turgor
Which statement describing urinary incontinence in an elderly client is true? a) Urinary incontinence in the elderly population can't be treated. b) Urinary incontinence isn't a disease. c) Urinary incontinence is a normal part of aging. d) Urinary incontinence is a disease
b) urinary incontinence isn't a disease
Which of the following is a common method of evaluating the urine output for newborns, infants, and toddlers who are not potty trained. a) Monitoring the amount of time for breast feeding b) Weighing the diaper before and after micturition c) Weighing the child before and after feeds d) Measuring the formula before the child ingests it
b) weighing the diaper before and after micturition
The nurse is caring for an adolescent client who is in the intensive care unit after a suicide attempt with barbiturate drugs and alcohol. The client is hypotensive with a mean arterial pressure (MAP) below 30 and a urine output that has decreased from 30 mL/hr to 2 mL/hr. Serum creatinine and potassium are both elevated. The parents of the client notice the small amount of urine in the indwelling catheter drainage bag and ask why there is so little. What is the best response by the nurse? a) "The potassium has crystallized in the renal tubules." b) "The body is conserving fluids to dilute the barbiturates." c) "There is not enough blood getting to the kidneys." d) "Alcohol immediately destroys the cells of the kidneys."
c) " There is not enough blood getting to the kidneys"
The HCP has prescribed a sterile urine specimen on a 3-year-old boy with a history of recurrent UTIs. The family is upset because the last time the cild was catheterized the procedure was very painful and traumatic. The nurse should tell the family: a) "I will request a prescription for a sedative to help him relax." b) "I can't do anything to reduce the pain, but you can hold him during the procedure." c) "I will get a prescription for a lidocaine-based lubricant to make the procedure more comfortable." d) "I can apply a topical anesthetic 20 minutes before placing the catheter."
c) "I will get a prescription for a lidocaine-based lubricant to make the procedure more comfortable."
The triage nurse in the pediatrician's office returns a call to a mother who is breastfeeding her 4-day-old infant. The mother is concerned about the yellow seedy stool that has developed since discharge home. What is the best reply by the nurse? a) "This type of stool indicates the infant may have diarrhea and should be seen in the office today." b) "The stool results from the gassy food eaten by the mother. Refrain from eating these foods while breastfeeding." c) "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding." d) "The stool will transition into a soft, brown, formed stool within a few days and is appropriate for breastfeeding."
c) "Soft and seedy unformed stools with each feeding are normal for this age and will continue through breastfeeding."
A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 ml. Urine output that's less than 50 ml in 24 hours is known as: a) oliguria. b) hematuria. c) anuria. d) polyuria.
c) anuria
A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? a) Encouraging the client to increase the time between voiding b) Restricting fluid intake to reduce the need to void c) Assessing present voiding patterns d) Establishing a predetermined fluid intake pattern for the client
c) assessing present voiding patterns
A client has been unable to void since having abdominal surgery 7 hours ago. The nurse should first: a) notify the health care provider (HCP). b) encourage the client to increase oral fluid intake. c) assist the client up to the toilet to attempt to void. d) insert an intermittent urinary catheter.
c) assist the client up to the toilet to attempt to void
A 24-year-old female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of acute cystitis (UTI). When obtaining the client's history, the nurse should ask the client if she has had: a) fever and chills. b) flank pain and nausea. c) frequency and burning on urination. d) hematuria.
c) frequency and burning on urination
A nurse is planning care for an adult who is hospitalized for diarrhea and dehydration. The client is receiving intravenous fluids but continues to have watery stools. The nurse reviews the intake and output record for the last 24 hours (view the chart). Which action should the nurse take? I/O 7AM: 500mL, 1000mL 3PM: 1000mL, 1500mL 11PM: 1000ML, 1700mL 7AM: 1500mL, 2500mL a) Have the client suck on ice chips. b) Administer an antiemetic. c) Restrict fluids. d) Increase fluids.
c) increase fluids
A client who has skeletal traction to stabilize a fractured femur has not had a bowel movement for 2 days. The nurse should: a) administer an oil retention enema. b) place the client on the bedpan every 3 to 4 hours. c) increase the client's fluid intake to 3,000 mL/day. d) perform passive range of motion to extremities
c) increases the client's fluid intake to 3,000 mL/day
The nurse is caring for a postoperative client who has not voided since before surgery. Which is the nurse's most appropriate action? a) Request an order to insert a Foley catheter b) Initiate hourly intake and output measurement c) Palpate for the bladder above the symphysis pubis d) Force fluids to encourage voiding
c) palpate for the bladder about the symphysis pubis
A client returned from surgery eight hours ago and has not voided. Which action should the nurse take first? a) Catheterize the client with a straight catheter. b) Tell the client to bear down and try to void. c) Palpate over the synthesis pubis for fullness. d) Call the physician to report the client's condition.
c) palpate over the synthesis pubis for fullness
The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent: a) appliance separation. b) the need to restrict fluids. c) urine reflux into the stoma. d) urine leakage.
c) urine reflux into the stoma
A client who has been diagnosed with bladder cancer is scheduled for an ileal conduit. Preoperatively, the nurse reinforces the client's understanding of the surgical procedure by explaining that an ideal conduit: a) diverts urine into the sigmoid colon, where it is expelled through the rectum. b) creates an opening in the bladder that allows urine to drain into an external pouch. c) is a temporary procedure that can be reversed later. d) conveys urine from the ureters to a stoma opening on the abdomen.
d) conveys urine from the ureters to a stoma opening on the abdomen
An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. See the accompanying chart. Based on these findings, the nurse should: I/O Day 1: 1850mL, 1550mL Day 2: 2200mL, 1150mL a) restrict the client's fluids. b) increase the client's fluids. c) continue monitoring intake and output. d) notify the health care provider (HCP).
d) notify the health care provider (HCP)
An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? a) Administer a phosphor-soda enema when necessary. b) Take a mild laxative such as magnesium citrate when necessary. c) Administer a tap-water enema weekly. d) Take a stool softener such as decussate sodium daily
d) take a stool softener such as decussate sodium daily
A nurse is caring for a client with severe burns and receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? a) pulse rate of 112 ppm b) serum sodium level of 136 mEq/L (136 mmol/L) c) blood pressure of 94/64 mm Hg d) urine output of 30 mL/h
d) urine output of 30 mL/h