Fundamentals Exam 5
A nurse working in a hospital includes abdominal assessment as part of patient assessment. In which patients would a nurse expect to find decreased or absent bowel sounds after listening for 5 minutes? Select all that apply. a.) A patient diagnosed with peritonitis b.) A patient who is on prolonged bedrest c.) A patient who has diarrhea d.) A patient who has gastroenteritis e.) A patient who has an early bowel obstruction f.) A patient who has paralytic ileus caused by surgery
a, b, f. Decreased or absent bowel sounds—evidenced only after listening for 5 minutes signify the absence of bowel motility, commonly associated with peritonitis, paralytic ileus, and/or prolonged immobility. Hyperactive bowel sounds indicate increased bowel motility, commonly caused by diarrhea, gastroenteritis, or early bowel obstruction.
A nurse is caring for a patient who has an NG tube in place for gastric decompression. Which nursing actions are appropriate when irrigating an NG tube connected to suction? Select all that apply. a.) Draw up 30 mL of saline solution into the syringe. b.) Unclamp the suction tubing near the connection site to instill solution. c.) Place the tip of the syringe in the tube to gently insert saline solution. d.) Place the syringe in the blue air vent of a Salem sump or double-lumen tube. e.) After instilling irrigant, hold the end of the NG tube over an irrigation tray. f.) Observe for return flow of NG drainage into an available container.
a, c, e, f. The nurse irrigating an NG tube connected to suction should draw up 30 mL of saline solution (or the amount indicated in the order or policy) into the syringe, clamp the suction tubing near the connection site to protect the patient from leakage of NG drainage, place the tip of the syringe in the tube to gently insert the saline solution, then place the syringe in the drainage port, not in the blue air vent of a Salem sump or double-lumen tube (the blue air vent acts to decrease pressure built up in the stomach when the Salem sump is attached to suction). After instilling irrigant, hold the end of the NG tube over an irrigation tray or emesis basin, and observe for return flow of NG drainage into an available container.
A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. a.) A 78-year-old male patient diagnosed with an enlarged prostate b.) An 83-year-old female patient who is on bedrest c.) A 75-year-old female patient who is diagnosed with vaginal prolapse d.) An 89-year-old male patient who has dementia e.) A 73-year-old female patient who is taking antihistamines to treat allergies f.) A 90-year-old male patient who has difficulty walking to the bathroom
a, c, e. Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.
A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. a.) Measure the patient's fluid intake and output. b.) Keep the skin around the stoma moist. c.) Empty the appliance frequently. d.) Report any mucus in the urine to the primary care provider. e.) Encourage the patient to look away when changing the appliance. f.) Monitor the return of intestinal function and peristalsis.
a, c, f. When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.
A nurse is caring for an older adult who has constipation. Which laxative would be contraindicated for this patient? a.) A saline osmotic laxative b.) A bulk-forming laxative c.) Methylcellulose d.) A stool softener
a. Certain saline osmotic laxatives can lead to fluid and electrolyte imbalances and should not be used in older adults or those with kidney or cardiac disease.
A nurse is preparing a hospitalized patient for a colonoscopy. Which nursing action is the recommended preparation for this test? a.) Have the patient follow a low-fiber diet several days before the test. b.) Have the patient take bisacodyl and ingest a gallon of bowel cleaner on day 1. c.) Prepare the patient for the use of general anesthesia during the test. d.) Explain that barium contrast mixture will be given to drink before the test.
a. If possible, a low-residue diet (low fiber) should be followed several days before the procedure. Most will maintain the low-residue diet; others may have full liquid diet the day before the procedure. There are multiple types of bowel preps for this procedure. The provider performing the procedure will decide which is best for the individual patient. The prep is usually given as a split dose, with half being given the night before and rest the morning of the procedure. It is recommended the second dose be given at least 5 hours and completed at least 2 hours before the study. There are some who may receive the prep the same day as the procedure, especially if the procedure is scheduled for later in the day. Conscious sedation, not general anesthesia, will be given for the colonoscopy. A chalky-tasting barium contrast mixture is given to drink before an upper gastrointestinal and small-bowel series of tests.
A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What action would be a priority when caring for this patient? a.) Preventing the tubing from kinking to maintain free urinary drainage b.) Not removing the sheath for any reason c.) Fastening the sheath tightly to prevent the possibility of leakage d.) Maintaining bedrest at all times to prevent the sheath from slipping off
a. The catheter should be allowed to drain freely through tubing that is not kinked. It also should be removed daily to prevent skin excoriation and should not be fastened too tightly or restriction of blood vessels in the area is likely. Confining a patient to bedrest increases the risk for other hazards related to immobility.
A nurse is assessing the abdomen of a patient who is experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action would the nurse perform next? a.) Auscultate the abdomen using an orderly clockwise approach in all abdominal quadrants. b.) Percuss all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen. c.) Lightly palpate over the abdominal quadrants; first checking for any areas of pain or discomfort. d.) Deeply palpate over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses.
a. The sequence for abdominal assessment proceeds from inspection, auscultation, percussion, and then palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. Percussion and deep palpation are usually performed by advanced practice professionals.
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? a.) dehydration b.) hypovolemia c.) balanced fluids d.) renal failure
a.) dehydration The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The symptoms are not associated with hypovolemia, balanced fluids, nor renal failure.
A nurse caring for a patient's hemodialysis access documents the following: "5/10/20 0930 AV fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider? a.) Positive bruit noted. b.) Area is warm to touch and edematous. c.) Patient denies pain and tenderness. d.) Positive thrill noted.
b. The nurse would report a site that is warm and edematous as this could be a sign of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein. If these are not present, the access may be cutting off. No report of pain is a normal finding.
A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow? a.) The nurse would use different equipment for catheterization of male versus female patients. b.) The nurse should use the smallest appropriate indwelling urinary catheter. c.) The nurse should always sterilize the equipment prior to insertion. d.) The nurse should choose a 12F, 5-mL or 10-mL balloon, unless ordered otherwise.
b. The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient (ANA, 2014; SUNA, 2015a). The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16F gauge commonly used (Bardsley, 2015a). A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise (ANA).
The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? a.) "begin the collection when you first urinate in the morning" b.) "discard your first urine and begin the collection after that" c.) "start collecting the urine with the next time you urinate" d.) you will need to have a catheter inserted for this collection"
b.) "discard your fist urine and begin the collection after that" The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.
The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? a.) loosen the internal muscles used to prevent or interrupt urination b.) keep muscles contracted for at least 10 seconds c.) relax muscles for at least 5 minutes between Kegels d.) perform these exercises two times daily for a week
b.) keep muscles contracted for at least 10 seconds. 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.
Which urinary care teaching will the nurse provide to a young adult female client? a.) wipe from the back to the front b.) refrain from douching unless ordered by a health care provider c.) if you do not feel like voiding, still strain to make sure the bladder is empty d.) drink water more frequently in the morning and evening to facilitate hydration
b.) refrain from douching unless ordered by a health care provider. Douching is not recommended unless ordered by the health care provider. Female clients should be taught to wipe from the urinary area towards the rectum to decrease the risk for introducing pathogens into the urethra. Straining is not appropriate. Water should be consumed throughout the day, not just in the morning and evening.
A nurse is administering a large-volume cleansing enema to a patient prior to surgery. Once the enema solution is introduced, the patient reports severe cramping. What nursing intervention would the nurse perform next based on this patient reaction? a.) Elevate the head of the bed 30 degrees and reposition the rectal tube. b.) Place the patient in a supine position and modify the amount of solution. c.) Lower the solution container and check the temperature and flow rate. d.) Remove the rectal tube and notify the primary care provider.
c. If the patient reports severe cramping with introduction of an enema solution, the nurse should lower the solution container and check the temperature and flow rate. If the solution is too cold or the flow rate too fast, severe cramping may occur. The head of the bed may be elevated 30 degrees for the patient's comfort if the patient needs to be placed on a bedpan in the supine position while receiving the enema.
A patient has a fecal impaction. Which nursing action is correctly performed when administering an oil-retention enema for this patient? a.) The nurse administers a large volume of solution (500 to 1,000 mL) b.) The nurse mixes milk and molasses in equal parts for an enema c.) The nurse instructs the patient to retain the enema for at least 30 minutes d.) The nurse administers the enema while the patient is sitting on the toilet
c. The patient should be instructed to retain the enema solution for at least 30 minutes or as indicated in the manufacturer's instructions. The usual amount of solution administered with a retention enema is 150 to 200 mL for an adult. The milk and molasses mixture is a carminative enema that helps to expel flatus. The patient should be instructed to lie on the left side of the bed as dictated by patient condition and comfort.
The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? a.) "I will place a bath blanket over the client to provide privacy" b.) "the client will be placed in a reclining position with knees bent" c.) "I will use clean gloves to handle the catheter and other equipment" d.) "washing hands before and after the procedure is important"
c.) "I will use clean gloves to handle the catheter and other equipment" Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse.
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. a.) dry the perineal area after urination or defecation from the back to the front b.) take baths instead of showers c.) drink two 8-oz glasses (480mL) of water before and after sexual intercourse and void immediately after intercourse d.) wear underwear with a cotton crotch e.) avoid clothing that is tight and restrictive on the lower half of the body
c.) drink two 8-oz glasses (480mL) of water before and after sexual intercourse and void immediately after intercourse d.) wear underwear with a cotton crotch e.) avoid clothing that is tight and restrictive on the lower half of the body Client education can help prevent UTI recurrence. Teaching the client about measures that promote health and decrease the severity and incidence of UTIs is a major nursing responsibility. The nurse should instruct the client to drink eight to ten 8-oz glasses (1,920 to 2,400 mL) of water daily, drink two 8-oz glasses (480 mL) of water before and after sexual intercourse, void immediately after sexual intercourse, wear underwear with a cotton crotch, and 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.
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? a.) remove the catheter every 8 hours, or more often in humid weather b.) wipe the penis throughly with an alcohol swab and dry throughly before application c.) fasten the condom securely enough to prevent leakage without constricting blood flow d.) ensure the tip of the tubing is touching the tip of the clients penis
c.) fasten the condom securely enough to prevent leakage without constricting blood flow. Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1 to 2 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.
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? a.) checking for blood return in the CVC b.) placing the client as N.P.O. status c.) notifying the health care provider of the assessment findings d.) obtaining laboratory studies
c.) notifying the health care provider of the assessment findings. The assessment is indicative of hospital-acquired catheter infection associated with the CVC. The medical provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Checking for blood return is not indicated and access to the CVC used for hemodialysis should not be attempted without a prescription to do so from the health care provider.
A client who is a paraplegic as a result of an auto accident has incontinence. The nurse correctly recognizes that which type of incontinence is most likely? a.) stress b.) urge c.) reflex d.) functional
c.) reflex An involuntary loss of urine that occurs at somewhat predictable intervals when a specific bladder volume is reached is called reflex incontinence. The person is unable to sense bladder fullness because of neurologic impairment, and the bladder simply empties when a certain degree of bladder stretch occurs. Bladder emptying occurs at the sacral reflex level because of impairment of the connection to the cerebrum that allows voluntary inhibition of voiding. Reflex incontinence is seen in clients with neurologic impairment, such as a spinal cord lesion, cerebrovascular accident, or brain tumor. The sudden, involuntary loss of small amounts (less than 50 mL) of urine that accompanies a sudden increase in intra-abdominal pressure is called stress incontinence, termed urge incontinence. The person with urge incontinence is unable simultaneously to perceive a full bladder and to hold urine until reaching the bathroom. Functional incontinence involves the inability or unwillingness of a person with normal bladder and sphincter control to reach the bathroom in time to void.
The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence? a.) stress incontinence b.) functional incontinence c.) total incontinence d.) overflow incontinence
c.) total incontinence Total incontinence may be the result of surgery, trauma, or physical malformation; the client has continuous and unpredictable loss of urine. Stress incontinence is related to an increase in intra-abdominal pressure and commonly occurs during activities such as coughing and sneezing. Overflow incontinence is associated with overdistention and overflow of the bladder, whereby the signal to empty the bladder is lost, the bladder fills, and the client dribbles urine. Functional incontinence occurs because the client is unable to reach the toilet.
A nurse prepares to assist a patient with a newly created ileostomy. Which recommended patient teaching points would the nurse stress? Select all that apply. a.) "When you inspect the stoma, it should be dark purple-blue." b.) "The size of the stoma will stabilize within 2 weeks." c.) "Keep the skin around the stoma site clean and moist." d.) "The stool from an ileostomy is normally liquid." e.) "You should eat dark-green vegetables to control the odor of the stool." f.) "You may have a tendency to develop food blockages."
d, e, f. Ileostomies normally have liquid, foul-smelling stool. The nurse should encourage the intake of dark-green vegetables because they contain chlorophyll, which helps to deodorize the feces. Patients with ileostomies need to be aware they may experience a tendency to develop food blockages, especially when high-fiber foods are consumed. The stoma should be dark pink to red and moist. Stoma size usually stabilizes within 4 to 6 weeks, and the skin around the stoma site (peristomal area) should be kept clean and dry.
A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? a.) The stoma is hard and dry. b.) The stoma is a pale pink color. c.) The stoma is swollen. d.) The stoma is a purple-blue color.
d. A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should subside with time. A normal stoma should be moist and dark pink to red in color.
A nurse is planning a bowel-training program for a patient with frequent constipation. What is a recommended intervention? a.) Using a diet that is low in bulk b.) Decreasing fluid intake to 1,000 mL c.) Administering an enema once a day to stimulate peristalsis d.) Monitoring bowel movements
d. For a bowel-training program to be effective, the nurse should monitor bowel movements including frequency, consistency, shape, volume and color, as appropriate, monitor bowel sounds, teach patient about specific foods that are assistive in promoting bowel regularity, ensure privacy, and encourage adequate fluid intake.
A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? a.) Teach the patient that incontinence is a normal occurrence with aging. b.) Ask the patient's family to purchase incontinence pads for the patient. c.) Teach the patient to perform PFMT exercises at regular intervals daily. d.) Insert an indwelling catheter to prevent skin breakdown.
c. Kegel exercises may help a patient regain control of the micturition process. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. An indwelling catheter is the last choice of treatment.
The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? a.) The male urethra is more vulnerable to injury during insertion. b.) In the hospital, a clean technique is used for catheter insertion. c.) The catheter is inserted 2 to 3 in into the meatus. d.) Since it uses a closed system, the risk for UTI is absent.
a. Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6 to 8 in. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.
A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? a.) Decreased and highly concentrated b.) Decreased and highly dilute c.) Increased and concentrated d.) Increased and dilute
a. Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.
A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish red today; is there something wrong with me?" What would be the nurse's best response? a.) "This is a normal finding when taking phenazopyridine." b.) "This may be a sign of blood in the urine." c.) "This may be the result of an injury to your bladder." d.) "This is a sign that you are allergic to the medication and must stop it."
a. Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine; the patient needs to be aware of this.
A nurse is caring for a patient who is post-surgical following an IPAA. For which adverse effect would the nurse monitor in this patient? a.) Incontinence b.) Constipation c.) Electrolyte imbalances d.) Infection
a. The outcomes for this IPAA surgery are not always ideal, and many patients experience decreased quality of life due to frequent defecation and fecal seepage and incontinence.
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? a.) auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration b.) administer an IV on the arm high above the access site c.) perform venipuncture below the access site to obtain a blood sample for laboratory testing d.) measure the client's blood pressure on the arm above the access site
a.) auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.
Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. a.) contact the health care provider to ask for an order for catheter discontinuation b.) delegate catheter discontinuation to the UAP c.) perform, or allow client to perform, perineal hygiene at least once daily d.) ensure that the drainage bag is above the level of the bladder at all times e.) discontinue the catheter and report this to the health care provider
a.) contact the health care provider to ask for an order for catheter discontinuation c.) perform, or allow client to perform, perineal hygiene at least once daily The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.
A nurse assesses the stool of patients who are experiencing gastrointestinal problems. In which patients would diarrhea be a possible finding? Select all that apply. a.) A patient who is taking narcotics for pain b.) A patient who is taking metformin for type 2 diabetes mellitus c.) A patient who is taking diuretics d.) A patient who is dehydrated e.) A patient who is taking amoxicillin for an infection f.) A patient taking over-the-counter antacids
b, e, f. Diarrhea is a potential adverse effect of treatment with amoxicillin clavulanate, metformin, or over-the-counter antacids. Narcotics, diuretics, and dehydration may lead to constipation.
After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? a.) Pouring warm water over the patient's fingers. b.) Having the patient ignore the urge to void until her bladder is full. c.) Using a warm bedpan when the patient feels the urge to void. d.) Stroking the patient's leg or thigh.
b. Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding.
For which patient would a nurse expect the primary care provider to order colostomy irrigation? a.) A patient with IBS b.) A patient with a left-sided end colostomy in the sigmoid colon c.) A patient with post-radiation damage to the bowel d.) A patient with Crohn's disease
b. Irrigations are used to promote regular evacuation of distal colostomies. Colostomy irrigation may be indicated in patients who have a left-sided end colostomy in the descending or sigmoid colon, are mentally alert, have adequate vision, and have adequate manual dexterity needed to perform the procedure. Contraindications include IBS, peristomal hernia, post-radiation damage to the bowel, diverticulitis, and Crohn's disease
A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? a.) the client is on a low protein diet b.) the client is dehydrated c.) the client has a history of osteoarthritis d.) the client is lactose intolerant
b.) the client is dehydrated. 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 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? a.) grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand b.) use her left hand to spread the woman's labia and keep them spread until the catheter is inserted c.) perform hand hygiene between cleansing the woman's labia and inserting the catheter d.) insert the catheter with her left hand while supporting the woman with her right hand
b.) use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. 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.
A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply. a.) Wear underwear with a synthetic crotch b.) Take baths rather than showers c.) Drink 8 to 10 8-oz glasses of water per day d.) Drink a glass of water before and after intercourse and void afterward e.) Dry the perineal area after urination or defecation from the front to the back f.) Observe the urine for color, amount, odor, and frequency
c, e, f. It is recommended that a healthy adult drink 8 to 10 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse.
A nurse is assisting a patient to empty and change an ostomy appliance. When the procedure is finished, the nurse notes that the stoma is protruding into the bag. What would be the nurse's first action in this situation? a.) Reassure the patient that this is a normal finding with a new ostomy. b.) Notify the primary care provider that the stoma is prolapsed. c.) Have the patient rest for 30 minutes to see if the prolapse resolves. d.) Remove the appliance and redo the procedure using a larger appliance.
c. If the stoma is protruding into the bag after changing the appliance on an ostomy, the nurse should have the patient rest for 30 minutes. If the stoma is not back to normal size within that time, notify the health care provider. If the stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.
A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? a.) Irrigation of long-term urinary catheters is a routine order. b.) Irrigation is recommended to prevent the introduction of pathogens into the bladder. c.) A blood clot threatens to block the catheter. d.) It is preferred to irrigate the catheter rather than increase fluid intake by the patient.
c. The flushing of a tube, canal, or area with solution is called irrigation. Natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction (Gould et al., 2009; SUNA, 2015a). However, intermittent irrigation is sometimes prescribed to restore or maintain the patency of the drainage system. Sediment or debris, as well as blood clots, might block the catheter, preventing the flow of urine out of the catheter.
A nurse is performing digital removal of stool on a patient with a fecal impaction. During the procedure the patient tells the nurse she is feeling dizzy and nauseated, and then vomits. What should be the nurse's next action? a.) Reassure the patient that this is a normal reaction to the procedure. b.) Stop the procedure, prepare to administer CPR, and notify the primary care provider. c.) Stop the procedure, assess vital signs, and notify the primary care provider. d.) Stop the procedure, wait 5 minutes, and then resume the procedure.
c. When a patient reports dizziness or lightheadedness and has nausea and vomiting during digital stool removal, the nurse should stop the procedure, assess heart rate and blood pressure, and notify the health care provider. The vagus nerve may have been stimulated.
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? a.) this urinary diversion is only temporary b.) the client will need to change the urinary pouch every 4 hours c.) the client will have to wear an external appliance to collect urine d.) urination can be voluntarily controlled after the stoma heals from the initial surgery
c.) the client will have to wear an external appliance to collect urine. 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.
A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. a.) The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. b.) The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. c.) The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. d.) The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. e.) The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. f.) The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.
d, e, f. A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.
A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) upper gastrointestinal series. Which is the correct order in which the tests would normally be performed? a.) c, b, d, a b.) d, c, a, b c.) a, b, d, c d.) b, a, d, c
d. A fecal occult blood test should be done first to detect gastrointestinal bleeding. Barium studies should be performed next to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions. A barium enema and routine radiography should precede an upper gastrointestinal series because retained barium from an upper gastrointestinal series could take several days to pass through the gastrointestinal tract and cloud anatomic detail on the barium enema studies. Noninvasive procedures usually take precedence over invasive procedures, such as endoscopic studies, when sufficient diagnostic data can be obtained from them.
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least important for the evaluation process? a.) The incontinence pattern b.) State of physical mobility c.) Medications being taken d.) Age of the patient
d. Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the care plan.
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? a.) inability to control either urinary or bowel elimination b.) hygiene measures used to keep meatus and adjacent area of the catheter clean c.) use of a catheter to collect urine in a sterile environment d.) one or both ureters are surgically implanted elsewhere
d.) one or both of the ureters are surgically implanted elsewhere. The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.
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? a.) cloudy, foul odor b.) light yellow, clear c.) clear, colorless d.) strongly aromatic, dark amber
d.) strongly aromatic, dark amber The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.
