Health and Wellness 204: Exam 5

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure? a. Instilling 500 to 1000 mL of lukewarm tap water through the stoma b. Advising the client to hold the breath if cramping occurs during instillation of the solution c. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso d. Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamping the tubing to allow the solution to flow into the stoma

a. Instilling 500 to 1000 mL of lukewarm tap water through the stoma Clients with sigmoid colostomies may require irrigation of the stoma to promote regular colon emptying. Irrigation is performed by instilling 500 to 1000 mL of lukewarm tap water through the stoma and then allowing the irrigation solution and stool to drain into a collection bag. The nurse hangs the irrigation solution so that the bottom of the bag is level with the client's shoulder. The nurse inserts the irrigation tube without force into the stoma and unclamps the tubing to allow the solution to flow into the stoma. The nurse would clamp the tubing if cramping occurs and then resume the instillation as tolerated.

The nurse is caring for a postoperative patient who underwent bowel resection surgery that morning. The nurse assesses the patient's abdomen and notes that there are hypoactive bowel sounds. The patient is resting quietly without nausea or vomiting. What is the appropriate action of the nurse? a. Keep the patient NPO and document the findings in the chart. b. Administer a laxative suppository to stimulate peristalsis. c. Insert a Salem sump nasogastric tube to low continuous suction. d. Notify the surgeon and prepare the patient to return to surgery.

a. Keep the patient NPO and document the findings in the chart. The presence of hypoactive bowel sounds is an expected finding for the first hours after abdominal surgery. The patient should be kept NPO to prevent nausea and vomiting. A laxative should not be administered. A nasogastric tube is not needed unless the patient starts vomiting or a paralytic ileus develops.

Nurse Vic is monitoring the fluid intake and output of a female client recovering from an exploratory laparotomy. Which nursing intervention would help the client avoid a urinary tract infection (UTI)? a. Maintaining a closed indwelling urinary catheter system and securing the catheter to the leg b. Limiting fluid intake to 1 L/day c. Encouraging the client to use a feminine deodorant after bathing d. Encouraging the client to douche once a day after removal of the indwelling urinary catheter

a. Maintaining a closed indwelling urinary catheter system and securing the catheter to the leg Maintaining a closed indwelling urinary catheter system helps prevent introduction of bacteria; securing the catheter to the client's leg also decreases the risk of infection by helping to prevent urethral trauma. To flush bacteria from the urinary tract, the nurse should encourage the client to drink at least 10 glasses of fluid daily, if possible. Douching and feminine deodorants may irritate the urinary tract and should be discouraged.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse would place the client in which position? a. Modified left lateral position b. Modified right lateral position c. On the left side of the body, with the head of the bed elevated 45 degrees d. On the right side of the body, with the head of the bed elevated 45 degrees

a. Modified left lateral position For administering an enema, the client is placed in a modified left lateral position so that the enema solution can flow by gravity in the natural direction of the colon. The head of the bed is not elevated when administering an enema.

The nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder. Which action will the nurse take to facilitate this procedure? a. Obtain a Coudé catheter for insertion. b. Attach a leg bag to the catheter prior to insertion. c. Trim the pubic hair before cleaning the perineal area. d. Wait until the bladder is full to perform catheterization.

a. Obtain a Coudé catheter for insertion. A Coudé catheter is used when there is narrowing or constriction of the urethra, making insertion of a regular indwelling catheter difficult. The Coudé catheter has a special tip on the end that is designed to facilitate insertion of the catheter through the narrowed urethra caused by BPH. Coudé catheters may need to be placed using a metal wire introducer. Placement using an introducer typically is performed by a provider or the patient's urologist, to avoid damaging urethral tissue. Trimming the pubic hair will not facilitate catheterization. Attaching a leg bag to the catheter prior to insertion is not needed because a bedside collection bag will usually be used at first.

The nurse is caring for a 1-day postoperative client who is complaining of urinary retention. What are the initial assessment techniques or interventions the nurse would employ? Select all that apply. a. Palpation b. Inspection c. Percussion d. Auscultation e. Bladder scanner f. Insertion of Foley catheter

a. Palpation, b. Inspection, c. Percussion, e. Bladder scanner Focus on the subject, client complaint of urinary retention. Note the strategic word, initial, and the data in the question—client is postoperative day 1. Eliminate option 4 because auscultation of the bladder is not an appropriate assessment. Eliminate option 6 because inserting a Foley catheter carries a risk for infection and is not prescribed initially.

The nurse is caring for a male patient who will be performing intermittent self-catheterization at home. Which actions by the patient indicate the need for additional teaching about this procedure? (Select all that apply.) a. Patency of the balloon is tested prior to insertion of the catheter. b. The catheter is inserted another 2 inches after urine is seen in the tubing. c. The catheter is carefully secured to the leg to prevent accidental removal. d. The foreskin is returned to its natural position after the catheter is removed. e. Catheterization is performed regularly before the bladder becomes distended. f. Water-soluble lubricant is generously applied along the length of the catheter.

a. Patency of the balloon is tested prior to insertion of the catheter. c. The catheter is carefully secured to the leg to prevent accidental removal. f. Water-soluble lubricant is generously applied along the length of the catheter. Only 5 to 8 inches of the catheter tip are covered with water-soluble lubricant. Patency of the balloon is only checked when indwelling catheters are inserted. Intermittent catheters need not be secured to the patient's leg because they will be removed after the bladder is drained. The other actions are correct.

The nurse is caring for a patient who has developed kidney failure. Which test finding leads the nurse to contact the nephrologist and arrange for emergency hemodialysis? a. Potassium level 6.8 mmol/L b. Serum creatinine level of 2.8 mg/dL c. Large amounts of protein in the urine d. 1500 mL of retained urine in the bladder

a. Potassium level 6.8 mmol/L Patients in renal failure often require dialysis to reduce serum potassium levels to less than 5.5 mmol/L . Critically high serum potassium levels can lead to lethal arrhythmias and must be corrected promptly. Patients with advanced renal failure may require emergency hemodialysis if the potassium level does not lower with other methods (insulin and 50% dextrose, kayexalate). An elevated creatinine is consistent with kidney dysfunction. Large amounts of protein in the urine occurs in some diseases. 1500 mL of retained urine requires straight catheterization.

The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. The nurse recognizes which type of renal failure the patient most likely developed? a. Prerenal b. Renal c. Postrenal d. Mixed

a. Prerenal Prerenal failure occurs as a result of reduction in blood flow to the kidneys, which would occur with septic shock. Causes of prerenal failure include dehydration, vascular collapse, and low cardiac output. Structural issues with the kidneys, from primary glomerular diseases or vascular lesions, result in renal failure. Postrenal failure is related to a mechanical or functional obstruction of the flow of urine.

The nurse is caring for a patient who will undergo colonoscopy testing. Which intervention will the nurse include in the patient's plan of care for the day before the test? a. Provide the patient with zinc oxide skin barrier cream for the perineal area. b. Obtain an order for a gentle laxative to be given once the test is completed. c. Carefully assess the patient's ability to swallow liquids through a straw. d. Check the patient for allergies to shellfish and iodine-based contrast dyes.

a. Provide the patient with zinc oxide skin barrier cream for the perineal area. Complete bowel evacuation is required prior to colonoscopy so that the physician can visualize the interior of the large intestine. The patient will have multiple soft-liquid bowel movements as part of the bowel prep for the test, so skin barrier cream will be helpful to prevent perineal irritation. Laxatives will not be needed after the colonoscopy, and no contrast dyes are used.

The nurse is caring for a patient who is taking narcotic pain medication after surgery. Which breakfast choices will help prevent constipation and promote return to regular bowel function? a. Raisin bran with skim milk, fresh fruit, and wheat toast b. Pancakes with maple syrup, bacon, and coffee with cream c. Omelet with cheddar cheese, green pepper, and onions d. Bagel with cream cheese, and strawberry nonfat yogurt

a. Raisin bran with skim milk, fresh fruit, and wheat toast The postoperative patient taking narcotic pain medications is at risk for developing constipation. A high-fiber diet with plenty of liquids will help prevent this from occurring. Raisin bran, fruit, and wheat bread are all good sources of fiber.

The nurse is caring for a patient with an indwelling urinary catheter caused by severe prostate enlargement. Which is the priority nursing diagnosis for this patient? a. Risk for infection r/t indwelling urinary catheter b. Disturbed body image r/t presence of catheter c. Risk for contamination r/t potential leakage of urine on clothing d. Impaired urination r/t blockage of bladder outlet

a. Risk for infection r/t indwelling urinary catheter The presence of an indwelling urinary catheter puts the patient at high risk for urinary tract infection, and this is the highest priority diagnosis for the patient. Disturbed body image is not as important as the risk of infection. Risk for contamination is not a nursing diagnosis. Impaired urination was corrected by placement of the urinary catheter.

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? a. Stop the irrigation temporarily. b. Increase the height of the irrigation. c. Notify the primary health care provider. d. Medicate for pain and resume the irrigation.

a. Stop the irrigation temporarily. Colostomy irrigation is less commonly done; however, some clients irrigate to regulate colon emptying. If cramping occurs during colostomy irrigation, the irrigation flow is stopped temporarily, and the client is allowed to rest. Cramping may occur from an infusion that is too rapid or that is causing too much pressure. Increasing the height of the irrigation will cause further discomfort. The primary health care provider does not need to be notified. Medicating the client for pain is not the appropriate action in this situation.

The nurse is caring for a patient with the nursing diagnosis of Urge incontinence of urine related to urinary tract infection. Which statement is appropriate for the "as evidenced by" portion of the patient's diagnosis? a. Sudden leakage of urine when patient is unable to get to the toilet in time b. Continuous urine flow from the bladder regardless of attempts to use the toilet c. Leakage of urine from the bladder when the patient coughs, sneezes, or laughs d. Leakage of urine because the patient is unable to indicate need to use the toilet

a. Sudden leakage of urine when patient is unable to get to the toilet in time Urge incontinence of urine occurs when the patient has a sudden need to urinate but cannot get to the toilet in time. Continuous flow of urine is deemed total urinary incontinence. Leakage of urine when sneezing or coughing is stress incontinence. Functional incontinence occurs when the patient cannot indicate need to use the toilet.

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution would the nurse use for the irrigation? a. Tap water b. Sterile water c. Sterile distilled water d. Sterile lactated Ringer's

a. Tap water Warm tap water or saline solution is used to irrigate a colostomy. If the tap water is not suitable for drinking, bottled water needs to be used. The other options are incorrect solutions.

A patient is admitted to the hospital with severe diarrhea. The patient should be monitored for which complication associated with diarrhea? 1) Hypokalemia 2) Hypocalcemia 3) Hyperglycemia 4) Thrombocytopenia

1) Hypokalemia Diarrhea causes fluid loss and hypokalemia, not hypocalcemia, hyperglycemia, or thrombocytopenia.

The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, "For 3 days prior to testing, I should avoid eating 1) beef. 2) milk. 3) eggs. 4) oatmeal.

1) beef. The nurse should instruct the patient to avoid red meat, chicken, fish, horseradish, and certain raw fruits and vegetables for 3 days prior to fecal occult blood testing.

The nurse has taught a client how to manage constipation. Which action by the client would provide evidence of learning? (Select all that apply.) The patient: 1) increases his intake of high-fiber foods. 2) drinks at least four 8-ounce glasses of water a day. 3) goes to the bathroom to evacuate after meals. 4) takes a daily laxative.

1) increases his intake of high-fiber foods. 3) goes to the bathroom to evacuate after meals. The urge to defecate typically comes after eating; the nurse can help manage the patient's constipation by assisting the patient to the bathroom after meals. The nurse should also encourage the patient to increase his intake of high-fiber food and drink at least eight glasses of water a day (not four). Laxatives should be administered or taken only when absolutely necessary.

A client has just voided 50 mL, but reports that his bladder still feels full. The nurse's next actions should include: (Select all that apply.) 1) palpating the bladder height. 2) obtaining a clean-catch urine specimen. 3) performing a bladder scan. 4) asking the patient about his recent voiding history. 5) encouraging the patient to consume cranberry juice daily. 6) inserting a straight catheter to measure residual urine.

1) palpating the bladder height, 3) performing a bladder scan, 4) asking the patient about his recent voiding history. The nurse should palpate the bladder for distention. A bladder scan will yield a more accurate measurement of the postvoid residual urine. A detailed history of the client's recent voiding patterns will assist the nurse in determining the appropriate nursing diagnosis and developing a plan of care. A clean-catch urine specimen may be necessary if further assessment shows the potential of a urinary tract infection. Cranberry juice is sometimes used to in an effort to prevent urinary tract infection, although there is conflicting research to support this action. Inserting a straight catheter to measure residual urine is an invasive procedure with the risk of introducing microorganisms into the bladder and is usually unnecessary if the nurse has access to a portable bladder scanner.

The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowler's position 2) Left side-lying position 3) Supine, with the head of the bed lowered flat 4) Supine, with the head of bed raised to 30 degrees

2) Left side-lying position The nurse should position an immobile patient in a left side-lying position to irrigate his colostomy. Semi-Fowler's, supine with the bed lowered flat, and the supine position with the head of bed elevated to 30 degrees are not appropriate positions for colostomy irrigation.

The nurse in a long-term care facility is teaching a group of residents about increasing dietary fiber. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice and bananas

2) Oranges, raisins, and strawberries Oranges, raisins, and strawberries are high in fiber. White bread, pasta, and white rice are carbohydrates. Whole milk, eggs, and bacon are high in cholesterol. Peaches, orange juice, and bananas are sources of potassium.

The nurse is obtaining the history of a newly admitted patient. Which element in the history places the patient at risk for urinary tract infection? 1) Hypertension 2) Hypothyroidism 3) Diabetes mellitus 4) Hormonal contraceptive use

3) Diabetes mellitus Diabetes mellitus places the patient at risk for urinary tract infection because glucose in the urine provides a medium favorable for bacterial growth. Hypertension, hypothyroidism, and hormonal contraceptive use are not directly related to an increased risk for urinary tract infection.

Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) milk and cheese. 2) bread and pasta. 3) fruits and vegetables. 4) lean meats.

3) fruits and vegetables. The nurse should encourage the patient to increase his intake of foods rich in fiber because they promote peristalsis and defecation, thereby relieving constipation. Low-fiber foods, such as bread, pasta, and other simple carbohydrates, as well as milk, cheese, and lean meat, slow peristalsis.

Which blood level is commonly tested to help assess kidney function? 1) Hemoglobin 2) Potassium 3) Sodium 4) Creatinine

4) Creatinine The nurse would examine laboratory results for blood urea nitrogen and creatinine to assess kidney function. Hemoglobin, potassium, and sodium levels can be affected by kidney disease, but they do not directly assess kidney function.

The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patient's abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds

4) Hypoactive bowel sounds Hypoactive bowel sounds are low pitched, infrequent, and quiet. An abdominal bruit is a hollow, blowing sound found over an artery, such as the iliac artery. Normal bowel sounds are high pitched, with approximately 5 to 35 gurgles occurring every minute. Hyperactive bowel sounds are very high pitched and more frequent than normal bowel sounds.

The nurse is teaching an older female patient how to manage stress incontinence at home. She instructs her to contract her pelvic floor muscles for at least 10 seconds followed by a brief period of relaxation. What is this intervention called? 1) Prompted voiding 2) Crede technique 3) Valsalva maneuver 4) Kegel exercises

4) Kegel exercises Kegel exercises strengthen the pelvic floor muscles that support the uterus, bladder, and bowel. Doing Kegel exercises regularly can reduce urinary incontinence. These exercises involve tightening and relaxing the muscles around the vaginal area. Prompted voiding is a part of a bladder-training program in which the person learns to void based on a schedule, rather than to empty the bladder. The Crede technique is applying manual pressure with your hands to the top portion of the bladder to initiate a urine flow. The Valsalva is the maneuver in which a person tries to exhale forcibly with a closed glottis (the windpipe) so that no air exits through the mouth or nose, for example, in strenuous coughing, straining during a bowel movement, or lifting a heavy weight.

Which of the following would be a common nursing diagnosis for patient with an ileostomy? A) Disturbed body image B) Constipation C) Delayed growth and development D) Excess fluid volume

A) Disturbed body image Constipation does not occur with the Ileostomy because the drainage is liquid. Growth and development are not affected by the formation of an Ileostomy. Excess fluid volume is unlikely to occur because the drainage is liquid and probably continual.

A 76 year old female is admitted due to a recent fall. The patient is confused and agitated. The family members report that this is not normal behavior for the patient. They explain that the patient is very active in the community and cares for herself. Based on the information you have gathered about the patient, which physician's order takes priority? A. "Collect a urinalysis" B. "Collect a T3 and T4 level" C. "Insert a Foley Catheter" D. "Keep patient NPO"

A. "Collect a urinalysis" Elderly patients do NOT exhibit the typical signs and symptoms of a UTI. Instead, they may become confused, experience falls, become agitated etc. This can occurs in elderly patients who are normally alert and oriented and active. If this is seen in your patient, think UTI. Collecting a urinalysis (per MD order) is very important to help determine the sudden cause of confused/agitation and falling. If the U/A comes back positive for WBCs and bacteria the patient can start receiving the proper treatment.

The nurse instructs the ileostomy client to do which of the following as a part of essential care of the stoma? A. Cleanse the peristomal skin meticulously. B. Take in high-fiber foods such as nuts. C. Massage the area below the stoma. D. Limit fluid intake to prevent diarrhea.

A. Cleanse the peristomal skin meticulously. The peristomal skin must receive meticulous cleansing because the ileostomy drainage has more enzymes and is more caustic to the skin than colostomy drainage. Dry the skin completely before putting on the skin barrier or pouch. Watch for sensitivities and allergies to the adhesive, skin barrier, paste, tape, or pouch material. They can develop after weeks, months, or even years of using a product because the client can become sensitized over time.

You're caring for a patient with a sigmoid colostomy. The stool from this colostomy is: A. Formed B. Semisolid C. Semiliquid D. Watery

A. Formed A colostomy in the sigmoid colon produces a solid, formed stool. This is the most common type. It is located in the bottom part of the large intestine. The sigmoid colon moves waste to the rectum. Sigmoid colostomies produce stool that is more solid and regular than other colostomies.

A male client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: A. Increasing fluid intake to prevent dehydration. B. Wearing an appliance pouch only at bedtime. C. Consuming a low-protein, high-fiber diet. D. Taking only enteric-coated medications.

A. Increasing fluid intake to prevent dehydration. Because stool forms in the large intestine, an ileostomy typically drain liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. Monitor I&O. Note number, character, and amount of stools; estimate insensible fluid losses (diaphoresis). Measure urine specific gravity; observe for oliguria. Provides information about overall fluid balance, renal function, and bowel disease control, as well as guidelines for fluid replacement.

A patient has become very depressed postoperatively after receiving a colostomy for GI cancer. He does not participate in his colostomy care or looks at the stoma. An appropriate nursing diagnosis for this situation is: A. Ineffective Individual Coping B. Knowledge Deficit C. Impaired Adjustment D. Anxiety

A. Ineffective Individual Coping The patient is dealing with a disturbance in self-concept and difficulty coping with the newly established stoma. Encourage the patient/SO to verbalize feelings regarding the ostomy. Acknowledge normality of feelings of anger, depression and grief over a loss. Discuss daily "ups and downs" that can occur.

The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? A. Leaves the catheter in place and gets a new sterile catheter. B. Leaves the catheter in place and asks another nurse to attempt the procedure. C. Removes the catheter and redirects it to the urinary meatus. D. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.

A. Leaves the catheter in place and gets a new sterile catheter. The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2)

The client with a new colostomy is concerned about the odor from the stool in the ostomy drainage bag. The nurse teaches the client to include which of the following foods in the diet to reduce odor? A. Yogurt B. Broccoli C. Cucumbers D. Eggs

A. Yogurt The client should be taught to include deodorizing foods in the diet, such as beet greens, parsley, buttermilk, and yogurt. Drinking buttermilk and/or eating yogurt or parsley can help to reduce odors from colostomy and ileostomy bags. In the case of urostomy patients, asparagus and fish will make the urine smell stronger. Spinach also reduces odor but is a gas-forming food as well. Broccoli, cucumbers, and eggs are gas-forming foods.

During a head-to-toe assessment on a patient with a possible urinary tract infection, you perform costovertebral angle percussion. The costovertebral angle is found? A. between the bottom of the 12th rib and spine B. between the right upper quadrant and umbilicus C. between the sternal notch and angle of Louis D. between the ischial spine and umbilicus

A. between the bottom of the 12th rib and spine The costovertebral angle is located at the angle under the 12th rib and the spine. This is where the kidneys reside. If percussion is performed at this angle and tenderness is reported it may demonstrate the kidney is inflamed due to infection. Therefore, the patient may have a kidney infection.

Nurses should recommend avoiding the habitual use of laxatives. Which of the following is the rationale for this? A) They will cause a fecal impaction B) They will cause chronic constipation C) They change the pH of the Gastrointestinal track D) They inhibit the intestinal enzymes

B) They will cause chronic constipation Habitual use of laxatives is the most common cause of chronic constipation.

Mr. T is nervous about a colonoscopy scheduled for tomorrow. The nurse describes the test by explaining that it allows which of the following? A) Visual examination of the esophagus and stomach B) Visual examination of the large intestine C) Radiographic examination of the large intestine D) Fluoroscopic examination of the small intestine

B) Visual examination of the large intestine An esophagogastroduodenoscopy Allows visual examination of the esophagus and stomach. The radiographic examination of the large intestine refers to a barium enema, and a fluoroscopic Examination of the small intestines refers to an upper gastrointestinal series.

You're preparing a teaching plan for a 27 y.o. named Jeff who underwent surgery to close a temporary ileostomy. Which nutritional guidelines do you include in this plan? A. There is no need to change eating habits. B. Eat six small meals a day. C. Eat the largest meal in the evening. D. Restrict fluid intake.

B. Eat six small meals a day. To avoid overloading the small intestine, encourage the patient to eat six small, regularly spaced meals. An ileostomy closure surgery is done to reverse the ileostomy so the client can have bowel movements as he did before the surgery. Ileostomy closure surgery is usually done through the stoma.

The client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate post-op period for which of the following most frequent complications of this type of surgery? A. Intestinal obstruction B. Fluid and electrolyte imbalance C. Malabsorption of fat D. Folate deficiency

B. Fluid and electrolyte imbalance A major complication that occurs most frequently following an ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output to prevent this from happening. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Monitor I&O carefully, measure liquid stool. Weigh regularly. This provides direct indicators of fluid balance. Greatest fluid losses occur with an ileostomy, but they generally do not exceed 500-800 mL/day.

Before bowel surgery, Lee is to administer enemas until clear. During administration, he complains of intestinal cramps. What do you do next? A. Discontinue the procedure. B. Lower the height of the enema container. C. Complete the procedure as quickly as possible. D. Continue administration of the enema as ordered without making any adjustments.

B. Lower the height of the enema container. Lowering the height decreases the amount of flow, allowing him to tolerate more fluid. Position the patient on the left side, lying with the knees drawn to the abdomen. This eases the passage and flow of fluid into the rectum. Gravity and the anatomical structure of the sigmoid colon also suggest that this will aid enema distribution and retention.

A male client with a recent history of rectal bleeding is being prepared for a colonoscopy. How should the nurse position the client for this test initially? A. Lying on the right side with legs straight B. Lying on the left side with knees bent C. Prone with the torso elevated D. Bent over with hands touching the floor

B. Lying on the left side with knees bent For a colonoscopy, the nurse initially should position the client on the left side with knees bent. Preparation for a colonoscopy is the biggest complaint that most patients have about receiving the procedure, and is a primary reason for non-compliance to screening colonoscopies. The technician or nurse is there to assist with preserving stability and preventing the patient from rolling forward or backward. Also, they are there to help provide counter pressure to the abdomen to assist the endoscopist in navigating corners and turns.

During the first few days of recovery from ostomy surgery for ulcerative colitis, which of the following aspects should be the first priority of client care? A. Body image B. Ostomy care C. Sexual concerns D. Skin care

B. Ostomy care Although all of these are concerns the nurse should address, being able to safely manage the ostomy is crucial for the client before discharge. Patients may have comorbidities that affect their ability to manage their ostomy care. Conditions such as arthritis, vision changes, Parkinson's disease, or post-stroke complications may hinder a patient's coordination and function to manage the ostomy.

A male client has undergone a colon resection. While turning him, wound dehiscence with evisceration occurs. The nurse's first response is to: A. Call the physician. B. Place saline-soaked sterile dressings on the wound. C. Take blood pressure and pulse. D. Pull the dehiscence closed.

B. Place saline-soaked sterile dressings on the wound. The nurse should first place saline-soaked sterile dressings on the open wound to prevent tissue drying and possible infection. Ask the client to bend the knees to reduce abdominal tension. Note the color of the tissue before it is covered. Then, cover the moistened dressings with a sterile drape.

You're assessing the stoma of a patient with a healthy, well-healed colostomy. You expect the stoma to appear: A. Pale, pink and moist B. Red and moist C. Dark or purple-colored D. Dry and black

B. Red and moist Good circulation causes tissues to be moist and red, so a healthy, well-healed stoma appears red and moist. A stoma should be pink to red in color, preferably raised above skin level, and moist. Stomas that are flat or convex can still be healthy but they can present challenges in terms of ostomy management and directing waste into the pouch.

Mr. Jay has a fecal impaction. The nurse correctly administers an oil-retention Enema by doing which of the following? A) Administering a large volume solution 500 to 1000 ml B) Mixing milk and molasses and equal parts for an enema C) Instructing the patient to retain the enema for at least 30 seconds D) Administering the enema while the patient is sitting on a toilet

C) Instructing the patient to retain the enema for at least 30 seconds 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 flats, As does the Harrison flush procedure.

A 36 year old female, who is 29 weeks pregnant, reports she is experiencing burning when voiding. The physician orders a urinalysis. Which statement by the patient demonstrates she understands how to collect the specimen? A. "I'll hold the cup firmly against the urethra while collecting the sample." B. "I will cleanse back to front with the antiseptic wipe before peeing in the cup." C. "First, I will pee a small amount of urine in the toilet and then collect the rest in the cup." D. "I will be sure to drink a lot of fluids to keep the urine diluted before peeing into the cup."

C. "First, I will pee a small amount of urine in the toilet and then collect the rest in the cup." When collecting a urinalysis it is important to avoid contaminating the sample. So, the patient will collect the urine during mid-stream. The patient will void a small amount in the toilet and then void the rest into the cup (until it is halfway full). The cup should be placed a few inches away from the urethra and prior to voiding the patient should use an antiseptic wipe to cleanse the labia from front to back. It is best to collect the sample when the bladder has been full for 2-3 hours, therefore the urine in concentrated not diluted.

The nurse has given instructions to the client with an ileostomy about foods to eat to thicken the stool. The nurse determines that the client needs further instructions if the client starts to eat which of the following foods to make the stools less watery? A. Pasta B. Boiled rice C. Bran D. Low-fat cheese

C. Bran Foods that help thicken the stool of the client with an ileostomy include pasta, boiled rice, and low-fat cheese. Bran is high in dietary fiber and thus will increase the output of watery stool by increasing propulsion through the bowel. Ileostomy output is liquid. The addition or elimination of various foods can help thicken or loosen this liquid drainage.

A male client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse would offer which full liquid item to the client? A. Tea B. Gelatin C. Custard D. Popsicle

C. Custard Full liquid food items include items such as plain ice cream, sherbet, breakfast drinks, milk, pudding, and custard, soups that are strained, and strained vegetable juices. A clear liquid diet consists of foods that are relatively transparent. A patient prescribed a full liquid diet follows a specific diet type requiring all liquids and semi-liquids but no forms of solid intake.

The physician orders a urine culture on your patient in room 5505 with a urinary tract infection. In addition, the patient is ordered to start IV Bactrim (Sulfamethoxazole/Trimethoprim). How will you proceed with following this order? A. First, hang the antibiotic, and then collect the urine culture. B. First, hang the antibiotic and when the antibiotic is finished infusing collect the urine culture. C. First, collect the urine culture, and then hang the antibiotic. D. First, collect the urine culture and then hold the dose of the antibiotic until the urine culture is back from the lab.

C. First, collect the urine culture, and then hang the antibiotic. It is very important to collect the urine culture FIRST and then immediately hang the antibiotic. If the antibiotic is hung first it will decrease the lab's ability to properly identify the bacteria growing in the urine (hence the antibiotic is fighting the infection). It takes approximately 2 days for a urine culture result to come back. Therefore, antibiotic therapy should not be held. The patient needs treatment to prevent the infection from spreading.

In a client with diarrhea, which outcome indicates that fluid resuscitation is successful? A. The client passes formed stools at regular intervals. B. The client reports a decrease in stool frequency and liquidity. C. The client exhibits firm skin turgor. D. The client no longer experiences perianal burning.

C. The client exhibits firm skin turgor. A client with diarrhea has a nursing diagnosis of Deficient fluid volume related to excessive fluid loss in the stool. Expected outcomes include firm skin turgor, moist mucous membranes, and urine output of at least 30 ml/hr. Evaluate dehydration by observing skin turgor over the sternum and inspecting for longitudinal furrows of the tongue.

Which of the following is an appropriate nursing action to promote regular bowel habits? A) Encourage the patient to avoid moving his bowels until a certain time of day B) Encourage the patient to avoid excess fluid intake and too much fiber C) Avoid strenuous exercise to limit stress on the abdominal muscles and impair peristalsis D) Assisting the patient to a normal position as possible to defecate

D) Assisting the patient to a normal position as possible to defecate Sitting upright on a toilet or commode promotes defecation. If the patient must use a bedpan, raise the head of the bed 30 to 45°. Patient should be encouraged to move their bowels at their usual time of the day. However, the patient should not be encouraged to put off defecation if the urge arises before or after their usual time. Patient should be encouraged to consume 2000 to 3000 mL of fluid, preferably water, and increase fiber, to promote regular defecation. Regular exercise improves gastrointestinal activities and aids in defecation.

As the nurse prepares to assist Mrs. P with her newly created Ileostomy, She is aware of which of the following? A) An appliance will not be required on the continual basis B) The size of the stoma stabilizes within two weeks C) Irrigation is necessary for regulation D) Fecal drainage will be liquid

D) Fecal drainage will be liquid And appliance is usually required on a continual basis because the fecal drainage is liquid. Stomas size usually stabilizes within 4 to 6 weeks, and Ileostomy Irrigation is not necessary because fecal matter is liquid.

When teaching an elderly client how to prevent constipation, which of the following instructions should the nurse include? A. "Drink 6 glasses of fluid each day." B. "Avoid grain products and nuts." C. "Add at least 4 grams of bran to your cereal each morning." D. "Be sure to get regular exercise."

D. "Be sure to get regular exercise." Exercise helps prevent constipation. Urge the patient for some physical activity and exercise. Consider isometric abdominal and gluteal exercises. Movement promotes peristalsis. Abdominal exercises strengthen abdominal muscles that facilitate defecation.

You're providing discharge teaching to a female patient on how to prevent urinary tract infections. Which statement is INCORRECT? A. "Void immediately after sexual intercourse." B. "Avoid wearing tight fitting underwear." C. "Try to void every 2-3 hours." D. "Use scented sanitary napkins or tampons during menstruation."

D. "Use scented sanitary napkins or tampons during menstruation." Options A, B, C are all correct statements in how to avoid a UTI. Option D is wrong because the patient should AVOID scented sanitary napkins or tampons during menstruation. It is also best to use sanitary napkins that are NOT SCENTED and AVOID using tampons (scented or not scented).

You're assessing your patients during morning rounding. Which patient below is at MOST risk for developing a urinary tract infection? A. A 25 year old patient who finished a regime of antibiotics for strep throat 10 weeks ago. B. A 55 year old female who is post-opt day 7 from hip surgery. C. A 68 year old male who is experiencing nausea and vomiting. D. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence.

D. A 87 year old female with Alzheimer's disease who is experiencing bowel incontinence. This patient has many risks factors for developing a UTI. The patient is postmenopausal which leads to flora changes in the vaginal area. This can increase the risk of developing a UTI. In addition, bowel incontinence increases the risk of a UTI due to the anatomy of the female (short urethra) and the close proximity between the rectum to the urethra. Also, patients with Alzheimer's disease may experience bladder retention due to the inability to communicate the need to void which increases the amount of time the urine is left in the bladder. Option A is wrong because although antibiotics can increase the risk of developing a UTI the patient finished the antibiotics 10 weeks ago. Options B and C are wrong because they do not provide enough information to determine if the patients are at risk for a UTI.

Sitty, a 66 y.o. patient underwent a colostomy for a ruptured diverticulum. She did well during the surgery and returned to your med-surg floor in stable condition. You assess her colostomy 2 days after surgery. Which finding do you report to the doctor? A. Blanched stoma B. Edematous stoma C. Reddish-pink stoma D. Brownish-black stoma

D. Brownish-black stoma A brownish-black color indicates lack of blood flow, and maybe necrosis. Necrosis occurs if the blood supply to the stoma is restricted. Initially, the stoma will become a darker red/purple and may even turn black, which is an indication that the blood supply is impaired. It may also feel cold and hard to touch. It is vital that you seek urgent medical attention.

The client who has undergone the creation of a colostomy has a nursing diagnosis of Disturbed body image. The nurse would evaluate that the client is making the most significant progress toward identified goals if the client: A. Watch the nurse empty the colostomy bag. B. Look at the ostomy site. C. Read the ostomy product literature. D. Practice cutting the ostomy appliance.

D. Practice cutting the ostomy appliance. The client is expected to have a body image disturbance after a colostomy. The client progresses through normal grieving stages to adjust to this change. The client demonstrates the greatest deal of acceptance when the client participates in the actual colostomy care. Each of the incorrect options represents an interest in colostomy care but is a passive activity. The correct option shows the client is participating in self-care.

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? a. "The enema will be given while I am sitting on the toilet." b. "I would try and hold the fluid as long as possible after it is run in." c. "I know that there will be some cramping after the enema solution is run in." d. "I would tell the nurse if cramping occurs when the fluid is running in."

a. "The enema will be given while I am sitting on the toilet." The enema is never administered while on a toilet due to safety. The enema is administered while the client is in a left side-lying position with the right knee flexed. This allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. It is important for the client to retain the fluid for as long as possible to promote peristalsis and defecation. If the client complains of fullness or pain, the flow is stopped for 30 seconds and restarted at a slower rate. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum; this could increase cramping.

The nurse is caring for a patient who had a colonoscopy earlier that day. The patient states that he still feels very bloated after the procedure. What is the best action of the nurse? a. Assist the patient to ambulate in the hall. b. Insert a rectal tube to remove retained flatus. c. Administer an enema to stimulate peristalsis. d. Encourage oral intake of fluids and high-fiber foods.

a. Assist the patient to ambulate in the hall. Ambulation is a good way to promote peristalsis and relieve bloating. An enema should not be used after colonoscopy. A rectal tube is not needed. Eating high-fiber foods soon after colonoscopy may increase gas and bloating.

The nurse is caring for a patient who has just had an intravenous pyelography (IVP; an imaging test used to look at the kidneys and ureters.) completed. Which assessment is the nurse's highest priority after the patient returns from the test? a. Calculate the patient's intake and output. b. Monitor for discoloration of the patient's urine. c. Assess for possible iodine or shellfish allergies. d. Inquire if the patient has burning or pain with urination

a. Calculate the patient's intake and output. The nurse must carefully monitor the patient's intake and output after IVP testing to ensure that the patient's kidneys were not damaged by the contrast dye. PO fluid intake should be encouraged to facilitate excretion of the contrast dye. Urine is not discolored from the IVP. Burning or pain with urination should not occur after IVP testing because there is no instrumentation of the urinary tract. Assessment of allergies must be done before the IVP is done because iodine-based contrast is used.

The nurse is caring for a patient who will be having a colonoscopy the following morning. Which items must be removed from the patient's dinner tray since they are not allowed prior to the test? (Select all that apply.) a. Cherry-flavored gelatin b. Cream of chicken soup c. Glass of apple juice d. Coffee with cream and sugar e. Lemon-flavored Italian ice f. Can of ginger ale

a. Cherry-flavored gelatin, b. Cream of chicken soup, d. Coffee with cream and sugar Patients who will undergo colonoscopy testing should have a clear liquid diet the day before the exam, so cream of chicken soup and coffee creamer should not be consumed. Foods with red food coloring should also be avoided prior to colonoscopy.

The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for a severe infection. The patient now has frequent loose watery stools and a low-grade temperature. What is the most likely cause of the patient's new symptoms? a. Clostridium difficile infection b. Paralytic ileus c. Fecal impaction d. Salmonella food poisoning

a. Clostridium difficile infection Diarrhea, abdominal pain, and low-grade temperature after completing IV antibiotics are often caused by C. difficile infection.

The nurse has a prescription to obtain a 24-hour urine collection in a client with a renal infection. Which actions would the nurse take when collecting this specimen? Select all that apply. a. Explain the procedure to the client. b. Save all subsequent voidings after the first void during the 24-hour period. c. During the collection period, place the main container on ice or in a refrigerator. d. Have the client void at the end time, and place this specimen in the main container. e. Have the client void at the start time, and place this specimen in the main container.

a. Explain the procedure to the client. b. Save all subsequent voidings after the first void during the 24-hour period. c. During the collection period, place the main container on ice or in a refrigerator. d. Have the client void at the end time, and place this specimen in the main container. The nurse would first explain the procedure to the client and ask the client to void at the beginning of the collection period and to discard this urine sample. All subsequent voided urine is saved in a container, which is placed on ice or refrigerated. The client is asked to void at the finish time, and this sample is added to the collection. The container is labeled, placed on fresh ice, and sent to the laboratory immediately.

The nurse is caring for a postoperative patient who had a colostomy placed 2 days ago. The appliance needs to be changed for the first time. Which ostomy care actions can the nurse delegate to the nursing assistant? (Select all that apply.) a. Gently cleaning the stoma with warm water and a washcloth b. Assessing the stoma and incision for signs of infection or ischemia c. Obtaining needed supplies from the clean utility room d. Teaching the patient how to care for the ostomy after discharge e. Determining which type of ostomy appliance to use f. Application of skin protectant to the area surrounding the stoma

a. Gently cleaning the stoma with warm water and a washcloth, c. Obtaining needed supplies from the clean utility room, f. Application of skin protectant to the area surrounding the stoma. The nursing assistant can gently clean the stoma with warm water and a washcloth, obtain needed supplies, and apply skin protectant. The nurse is responsible for assessment, teaching, and determining which ostomy appliance to use.

The nurse is caring for a patient who periodically has small streaks of fresh red blood in the stool. The patient denies abdominal pain or loss of appetite. The nurse identifies what to be the most likely cause of this patient's bleeding? a. Hemorrhoids b. Bleeding gastric ulcer c. Colon polyps d. Perforated colon

a. Hemorrhoids Bleeding hemorrhoids can lead to small streaks of fresh red blood in the stool. Bleeding gastric ulcer would lead to black, tarry stools as the blood is digested. Colon polyps do not cause bleeding.

A client states to the home health nurse that they have not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? a. High-fiber diet b. Full liquid diet c. Low-fiber diet d. Low-sodium diet

a. High-fiber diet Constipation is the probable cause of the client's lack of bowel movements. Constipation is the difficult or infrequent passage of stools, which are hard and dry. Constipation has numerous causative factors, including psychogenic, lack of physical activity, inadequate intake of food and fiber, and medication influences. A high-fiber diet often is indicated for constipation because it will promote bulk and encourage intestinal peristalsis. A full liquid diet will add fluids but no bulk to help relieve the constipation. A low-fiber diet has little bulk to assist with the needed peristalsis. Decreasing the amount of sodium in the diet has little, if any, effect on constipation.

The nurse is caring for a patient who has an ileostomy. Which Nursing diagnosis has the highest priority for the patient? a. Impaired skin integrity r/t localized skin irritation from liquid stool b. Social isolation r/t potential leakage of stool from ostomy appliance c. Lack of knowledge r/t care and maintenance of ostomy appliance d. Disturbed body image r/t presence of stoma and altered elimination

a. Impaired skin integrity r/t localized skin irritation from liquid stool The highest priority Nursing diagnosis for this patient is impaired skin integrity because the liquid stool from the ileostomy quickly leads to breakdown when in contact with the skin. Open sores can lead to bacterial infection and significant discomfort for the patient. In addition, ostomy appliances do not adhere well to open wounds, increasing the risk for continuing skin breakdown. The other nursing diagnoses are appropriate for this patient but are not the highest priority.

The nurse is working with a new nursing assistant who is providing care to patients with urinary difficulties. Which actions by the nursing assistant indicates that additional teaching is required? (Select all that apply.) a. The length of the urinary catheter is cleaned up to the patient's perineum. b. A urine sample is obtained from the drainage bag immediately after catheter insertion. c. A fresh condom catheter is applied every other day following careful perineal care. d. Zinc oxide barrier cream is applied liberally to the perineal area for incontinent patients. e. The catheter drainage bag is disconnected in order to put pants on the patient. f. Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter.

a. The length of the urinary catheter is cleaned up to the patient's perineum. c. A fresh condom catheter is applied every other day following careful perineal care. e. The catheter drainage bag is disconnected in order to put pants on the patient. f. Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter. The urinary catheter must be cleaned from the urinary meatus down toward the drainage bag rather than up toward the perineum. A fresh condom catheter must be applied daily. The catheter drainage bag should not be disconnected to put pants on the patient. The drainage bag can be threaded through the pants leg before putting pants on the patient. Sterile technique should be used to obtain samples from the catheter.

The nurse is caring for a patient who is recovering from bowel surgery. Which assessment finding best indicates that the bowel is starting to resume function and the patient will be able to resume oral intake soon? a. The patient has bowel sounds x 4 quadrants and is passing gas. b. The patient has no nausea, and abdominal pain is minimal. c. The patient feels hungry for chicken soup and hot tea. d. The patient's nasogastric tube was discontinued the previous day.

a. The patient has bowel sounds x 4 quadrants and is passing gas. The presence of bowel sounds and passage of flatus indicate that the patient's bowels are starting to resume function and the patient will be able to resume oral intake soon. Hunger, discontinuation of the NG tube, or absence of nausea are not definite indicators of readiness to resume oral feedings.

The nurse is caring for a patient with a history of type 1 diabetes. Which assessment finding indicates to the nurse that the patient may not be compliant with the diabetic treatment regimen? a. The patient is always thirsty and frequently voids very large amounts of urine. b. The patient's urine is very concentrated with a dark amber color. c. The patient complains of throbbing flank pain and burning with urination. d. The patient has urinary hesitancy and difficulty initiating a stream of urine.

a. The patient is always thirsty and frequently voids very large amounts of urine. A noncompliant diabetic patient will have elevated blood sugars that cause thirst and polyuria. Concentrated urine indicates dehydration. Throbbing flank pain and burning with urination are indicative of urinary tract infection. Urinary hesitancy and difficulty initiating urine stream are not indicative of elevated blood sugar levels.

The nurse is caring for a patient who is to have a cleansing enema. Which assessment finding by the nurse indicates a need to contact the prescriber and question the order? a. The patient is recovering from a traumatic brain injury. b. The patient has not had a bowel movement for 3 days. c. The patient is to have a lower GI series the following morning. d. The patient had an upper GI series performed the previous day.

a. The patient is recovering from a traumatic brain injury. Patients with a traumatic brain injury often have increased intracranial pressure, which can be worsened with enema administration, thus putting the patient at risk for additional neurologic damage. The provider should be contacted and the order should be questioned. Constipation, preparation for a lower GI series, and removal of barium from the colon after upper GI series are all indications for a cleansing enema.

The nurse is caring for a patient who is recovering after hip surgery. The patient requires assistance to use the bathroom because no weight bearing is allowed on the right leg. Which goal is most important for the nurse to include for the diagnosis Impaired self-toileting? a. The patient will demonstrate safe transfer technique between wheelchair and toilet. b. The call light will be answered promptly when the patient needs to use the toilet. c. Toileting will be scheduled in the morning when the patient needs to defecate. d. Toilet paper and handwashing items will be kept within easy reach of the patient.

a. The patient will demonstrate safe transfer technique between wheelchair and toilet. The highest priority goal for this patient is the demonstration of safe transfer technique between the chair and the toilet. The other statements are interventions performed by staff rather than goals that will be accomplished by the patient.

The nurse is caring for a patient who has had a severe stroke and requires assistance to use the toilet. Which goal is the highest priority for this patient? a. The patient will remain continent with no perineal skin breakdown. b. The patient will state satisfaction with use of gait belt for toilet transfers. c. The patient will regain ability to pull up clothing after using the toilet. d. The patient will have privacy once properly positioned on the toilet.

a. The patient will remain continent with no perineal skin breakdown. The highest priority goal for this patient is continence with no perineal skin breakdown to maintain skin integrity and self-esteem. Patient statements of satisfaction and the ability to pull up clothing are important but not the priority over preventing skin breakdown. Privacy is an intervention to be performed by the staff rather than a goal for the patient.

The nurse is caring for an elderly patient whose dementia has become worse over the last 24 hours. The nurse suspects that the patient may have developed a urinary tract infection and obtains a urine sample. Which assessment findings prompt the nurse to contact the provider to obtain an order for urine culture and sensitivity testing? (Select all that apply.) a. Urinary dipstick testing is positive for nitrates. b. The urine appears cloudy with a foul odor. c. The urine is concentrated and dark amber in color. d. The urine smells faintly like sweet fruit. e. The patient is urinating more frequently than usual. f. The patient is normally continent but has been incontinent twice.

a. Urinary dipstick testing is positive for nitrates. b. The urine appears cloudy with a foul odor. e. The patient is urinating more frequently than usual. f. The patient is normally continent but has been incontinent twice. Concentrated dark urine indicates dehydration rather than infection of the urinary tract. Urine that smells of sweet fruit contains ketones from high blood sugar. Urine that is cloudy with a foul odor and positive for nitrites is most likely due to urinary tract infection. Frequent urination and incontinence are signs of urinary tract infection in the elderly.

The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine in the toilet. Which is the priority assessment to be performed by the nurse? a.Bladder scan to determine the amount of urine in the bladder b. Auscultation to assess circulation through the right and left renal arteries c. Bimanual palpation to assess for possible enlargement of the kidneys d. Calculate the patient's intake and output to check for fluid volume deficit

a.Bladder scan to determine the amount of urine in the bladder The patient with suspected urinary retention should have a bladder scan performed to determine the amount of urine in the bladder. If a significant amount of urine is found in the bladder, the provider may be notified to obtain an order for straight catheterization.

The nurse is caring for a patient who will undergo ultrasound testing of the bladder and kidneys the next morning. Which instruction will the nurse provide to the patient about the test? a. "A small IV will be inserted into your arm to inject the contrast dye." b. "You will need to drink lots of water but not use the toilet." c. "You should not have anything to eat or drink after midnight." d. "You will receive a cleansing enema before you have the test."

b. "You will need to drink lots of water but not use the toilet." No preparation is needed for kidney and bladder ultrasound other than having the patient drink lots of fluid beforehand. The patient is instructed not to use the toilet so that the bladder will be filled and easy to visualize. No contrast dye, enemas, or fasting is required.

Nurse Claudine is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? a. Fluid intake should be double the urine output b. Fluid intake should be approximately equal to the urine output c. Fluid intake should be half the urine output. d. Fluid intake should be inversely proportional to the urine output

b. Fluid intake should be approximately equal to the urine output Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output.

The nurse is caring for a patient who had prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake. The patient's urine from the indwelling catheter is cherry red with occasional small clots. What is the appropriate action of the nurse? a. Remove the urinary catheter and replace it with a new one. b. Gently irrigate the catheter using warmed sterile normal saline. c. Send a sample of the patient's urine to the laboratory for analysis. d. Call the provider and obtain an order for kidney and bladder ultrasound.

b. Gently irrigate the catheter using warmed sterile normal saline. The patient most likely has decreased urine output caused by clot formation that is blocking urine from draining through the catheter. The catheter should be gently irrigated using sterile technique and warmed sterile saline to loosen clots and facilitate urinary drainage. The catheter should not be removed. (this is a normal finding after surgery.) Ultrasound and urinalysis are not necessary.

The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What would the nurse do next? a. Immediately twist the catheter, and then slowly inflate the balloon. b. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. c. Insert the catheter until resistance is met, and then inflate the balloon. d. Withdraw the catheter approximately 1 in (2.5 cm), and then inflate the balloon.

b. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. The balloon is behind the opening at the catheter tip. The catheter is inserted 7 to 9 in (18 to 23 cm) after urine begins to flow, providing sufficient space to inflate the balloon and ensuring that the balloon has passed through the entire urethra and into the bladder. Inflating the balloon in the urethra could produce trauma. The catheter would be neither withdrawn nor advanced until resistance is met.

The nurse is caring for a patient who is to complete a 24-hour urine collection to measure creatinine clearance. Which tasks related to this test may be delegated to the nursing assistant? (Select all that apply.) a. Teaching the patient about sterile specimen collection b. Keeping the urine collection container cool on ice c. Dumping the urine from the patient's first void d. Restricting the patient's oral fluid intake during the test e. Transporting the specimen to the laboratory for testing f. Reminding the patient not to put toilet paper in the urine

b. Keeping the urine collection container cool on ice c. Dumping the urine from the patient's first void e. Transporting the specimen to the laboratory for testing f. Reminding the patient not to put toilet paper in the urine The nurse assistant can help the nurse by keeping the urine collection container cool on ice, dumping the urine from the patient's first void, and reminding the patient not to put toilet tissue in the urine specimen. The nurse assistant can also transport the specimen to the laboratory after the urine has been collected for 24 hours. Fluid intake should be encouraged during the test. Teaching the patient about the testing procedure is done by the nurse, although creatinine clearance testing does not require sterile technique.

The client has a prescription for the administration of an enema. After preparing the equipment and solution, the nurse would assist the client into which position? a. Right-sided lateral position b. Modified left lateral position c. Left side, with the head of the bed elevated 45 degrees d. Right side, with the head of the bed elevated 45 degrees

b. Modified left lateral position For the administration of an enema, the client is placed in a modified left lateral position so that the enema solution can flow by gravity in the natural direction of the colon. The client is lying on his or her side, with the body turned approximately 45 degrees. The lower leg is extended, with the upper leg flexed at the hip and knee to a 45- to 90-degree angle. Options 1, 3, and 4 are incorrect positions.

When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? a. The client sets the drainage bag on the floor while sitting down b. The client keeps the drainage bag below the bladder at all times c. The client clamps the catheter drainage tubing while visiting with the family d. The client loops the drainage tubing below its point of entry into the drainage bag

b. The client keeps the drainage bag below the bladder at all times To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because it could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.

The nurse is caring for a patient who is to undergo computed tomography (CT) of the kidneys and ureters. Which assessment finding by the nurse must be reported to the provider and radiologist before the patient has the procedure? a. The patient is allergic to bananas and latex. b. The patient thinks that she might be pregnant. c. The patient has a family history of bladder cancer. d. The patient currently has a urinary tract infection.

b. The patient thinks that she might be pregnant. CT requires exposure to radiation similar to an x-ray, so the patient's provider and radiologist should be notified promptly of the possibility of pregnancy. The other conditions do not preclude CT scan examination for the patient.

The nurse is caring for an elderly patient with a history of arthritis, urinary incontinence and poor perineal hygiene practices. The patient has had four urinary tract infections in the past year. Which is the priority goal for the nursing diagnosis Impaired health maintenance for this patient? a. The patient will be provided with educational materials about risks of urosepsis. b. The patient will allow family members to assist with daily bathing and perineal care. c. The patient will discuss the possible consequences of frequent UTIs. d. Regular home care nursing visits and follow-up telephone contact will be arranged.

b. The patient will allow family members to assist with daily bathing and perineal care. The priority for this patient is to improve personal hygiene and perineal care in order to reduce the risk of future urinary tract infections. The patient's agreement to allow family members to assist with bathing and perineal care will greatly reduce this risk. Providing educational materials about the risk of urosepsis, discussion of UTI consequences, and regular follow-up care are interventions rather than patient goals.

The nurse is caring for a patient who is experiencing stress incontinence. The nurse identifies which goal to be the most important for this patient? a. The patient will carefully complete a voiding diary for the duration of 2 weeks. b. The patient will not experience involuntary urination during coughing or sneezing. c. The patient will be able to recognize and effectively manage perineal dermatitis. d. The patient will demonstrate how to appropriately use urinary incontinence products.

b. The patient will not experience involuntary urination during coughing or sneezing. The patient with stress incontinence experiences loss of urine when coughing, sneezing, laughing, or exercising. The highest priority goal for this patient is to not experience incontinence at all and remain continent through all daily activities. If the patient remains continent, perineal dermatitis will not be a problem and urinary incontinence products will not be needed.

The nurse is caring for a seriously ill patient whose laboratory results show a serum creatinine level of 3.5 mg/dL and a serum BUN of 35 mg/dL. Which conclusion can the nurse draw from these test results? a. The patient is severely dehydrated. b. The patient's kidneys have been damaged. c. The patient has a urinary tract infection. d. The patient has developed a renal calculus.

b. The patient's kidneys have been damaged. (Normal Bun is 10-20, creatinine levels are 0.6-1.2) Elevated BUN and creatinine are found in laboratory test results when the kidneys have been damaged and are unable to sufficiently clear metabolic wastes from the bloodstream. A dehydrated patient may have an elevated BUN, but the serum creatinine should be normal. Urinary tract infection and kidney stone (renal calculus) would not cause elevated BUN and creatinine levels.

Nurse Agnes is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? a. Specific gravity of 1.03 b. Urine pH of 3.0 c. Absence of protein d. Absence of glucose

b. Urine pH of 3.0 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.

A female client with an indwelling urinary catheter is suspected of having a urinary tract infection. Nurse Angel should collect a urine specimen for culture and sensitivity by: a. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. b. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle c. draining urine from the drainage bag into a sterile container d. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

b. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be clamped (at distal portion of catheter) for no more than 30 minutes to allow urine to collect.

The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicates an understanding of the procedure? a. "The stoma needs to be cleaned with only water." b. "The best time to change the appliance is at night." c. "The pouch needs to be changed every 5 to 7 days." d. "I'll cut the skin barrier 10 millimeters larger than the stoma."

c. "The pouch needs to be changed every 5 to 7 days." Clients with urinary diversions need to be educated on the proper care of the urinary stoma. An appliance with an attached collection bag is placed over the stoma to collect urine. The most ideal time to change the appliance is in the morning, not at night. The stoma needs to be cleaned with both nonresidue soap and water, not just water. The skin barrier needs to be cut no more than 3 millimeters larger than the stoma to prevent urine leakage and irritation of the exposed skin. The pouch needs to be changed every 5 to 7 days. Therefore, option 3 indicates client understanding of the procedure.

The nurse is caring for a patient who will be undergoing upper GI series testing the next day. Which instruction will the nurse provide to the patient about the upcoming exam? a. "The back of your throat will be sprayed with numbing medicine." b. "You will need to have a clear liquid diet and take a laxative tonight." c. "You will be given a milky liquid to drink shortly before the test starts." d. "You should not take your dose of warfarin (Coumadin) tonight."

c. "You will be given a milky liquid to drink shortly before the test starts." The patient is given a milky barium liquid to drink as part of the upper GI series, so the patient should be informed of this. The back of the throat is numbed for upper GI endoscopy, not an upper GI series. Warfarin is not contraindicated prior to an upper GI series, and no bowel prep is required.

The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain? a. A straight catheter b. A Coudé tip catheter c. A triple-lumen catheter d. A double-lumen catheter

c. A triple-lumen catheter Straight catheters are used for intermittent catheterization. Double-lumen catheters are used for indwelling urinary catheterization in which one lumen drains urine in the bladder and the other lumen is used to inflate and deflate the balloon. Triple-lumen catheters are used for continuous bladder irrigation or bladder medication instillation. One lumen is to inflate and deflate the balloon, another lumen is to drain urine and the irrigation solution, and the other lumen instills the irrigation solution into the bladder. A Coudé tip catheter is a catheter with a curved tip at the end that is used to advance the catheter past a hypertrophied prostate, in which using a standard catheter would be difficult. Therefore, option 3 is correct.

After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a male client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should Nurse Anthony do first? a. Increase the I.V. flow rate b. Notify the physician immediately. c. Assess the irrigation catheter for patency and drainage d. Administer meperidine (Demerol), 50 mg I.M., as prescribed

c. Assess the irrigation catheter for patency and drainage Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic, such as meperidine, as prescribed. Increasing the I.V. flow rate may worsen the pain. Notifying the physician isn't necessary unless the pain is severe or unrelieved by the prescribed medication.

The nurse is caring for an incontinent male patient who has a deep decubitus ulcer on his sacrum. Which intervention will best manage the patient's urinary incontinence and facilitate healing of the ulcer? a. Use of disposable absorbable incontinence briefs b. Daily application of perineal barrier cream containing zinc oxide c. Careful perineal care and application of a condom catheter d. Insertion of a single-lumen straight urinary catheter

c. Careful perineal care and application of a condom catheter Condom catheters allow for collection of urine in the incontinent patient without the infection risks of an indwelling catheter. The condom catheter is applied to the outside of the penis like a condom instead of being inserted into the urethra. Careful perineal care is performed prior to application of the condom catheter and regularly thereafter. Use of disposable briefs or perineal barrier cream will not facilitate healing of the sacral ulcer. A single-lumen straight urinary catheter is used to drain the bladder to relieve urinary retention or to obtain a urine sample for testing. A straight catheter is not used for management of incontinence.

The nurse is caring for an immobile patient who has abdominal pain and frequent small, liquid stools. The patient vomited his breakfast and is still nauseated. Which action by the nurse is the highest priority? a. Provide oral care after each episode of emesis. b. Apply a skin barrier to the patient's perineal area. c. Check the patient for a fecal impaction. d. Administer antiemetic medication with a sip of water.

c. Check the patient for a fecal impaction. The patient who has abdominal pain and frequent small liquid stools should be checked for fecal impaction, especially since the patient is vomiting. Immobility is a risk factor for the development of fecal impaction. The other actions can be performed once fecal impaction is ruled out.

The nurse is caring for a patient who has diarrhea and identifies which priority nursing diagnosis for this patient? a. Lack of knowledge related to prescribed diet modifications b. Impaired nutritional intake related to poor appetite c. Diarrhea related to excessive loss of fluid through stool d. Anxiety related to incontinence with loose stools and need for clothing change

c. Diarrhea related to excessive loss of fluid through stool Dehydration is the priority nursing problem for this patient, so diarrhea is the most important Nursing diagnosis. Impaired nutritional intake, lack of knowledge, and anxiety can be addressed once fluid balance is restored.

The nurse is caring for a patient with benign prostatic hypertrophy (bph) who states that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of urine at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient? a. Anxiety r/t continual urge to urinate b. Reflex incontinence of urine r/t over-distention of the bladder c. Impaired urination r/t obstruction of urinary bladder outlet d. Impaired self-toileting r/t inability to pass urine into the toilet

c. Impaired urination r/t obstruction of urinary bladder outlet The patient has acute urinary retention with overflow as evidenced by 1100 mL of urine in the bladder and frequent passage of small amounts of urine. The priority nursing diagnosis is thus Impaired urination r/t obstruction of urinary bladder outlet. Urinary retention is the cause of the patient's discomfort and drainage of the bladder will result in relief of the patient's symptoms. The patient is able to get himself on and off the toilet so toileting self-care deficit is not a problem. Reflex incontinence of urine r/t over-distention of the bladder is not as specific to this scenario as the nursing diagnosis of impaired urination.

The nurse is caring for a patient who is to have testing for fecal occult blood. What step will the nurse perform during this testing? a. Keep the patient on a clear liquid diet for 72 hours. b. Send the samples to the laboratory while they are still warm. c. Inform the patient that several stool samples will be needed. d. Use a sterile container when collecting the stool samples.

c. Inform the patient that several stool samples will be needed. Three stool samples are required for fecal occult testing to avoid missing blood that appears intermittently. A sterile container is not required, and the patient does not need to be on a clear liquid diet for the test. Stool samples for culture and sensitivity should be sent to the laboratory when they are fresh and warm.

A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? a. Prone position b. Lithotomy position c. Left lateral side-lying position d. Right lateral side-lying position

c. Left lateral side-lying position (also known as sims) For digital removal of stool, the client would be placed in the left lateral side-lying position, as this position follows the anatomical curvature of the colon. Options 1, 2, and 4 are inappropriate positions for this procedure.

The nurse is caring for a patient with a neurological condition that causes constant severe thirst, drinking fluids continuously, and voiding 3 to 4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this patient's urinary output? a. Anuria b. Oliguria c. Polyuria d. Enuresis

c. Polyuria Urinary output greater than 2500 mL/day is polyuria. Insufficient urine output is oliguria, whereas absence of urine is anuria. Enuresis is commonly known as "bedwetting" at night.

The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching? a. Cleans the catheter proximally to distally with soap and water b. Maintains the urinary collection bag below the level of the bladder c. Removes a loose catheter anchor and places a new anchor on the lower leg d. Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position

c. Removes a loose catheter anchor and places a new anchor on the lower leg Routine catheter care is imperative in the prevention of catheter-associated urinary tract infections (CAUTIs). Meticulous technique needs to be used to prevent the introduction of microorganisms to the urinary tract. For uncircumcised persons, the nurse would retract the foreskin to inspect the urethral meatus for skin irritation and then cleanse the site with warm, soapy water and return the foreskin to its normal position. The catheter tubing needs to be cleaned in a proximal to distal direction. The urinary drainage bag needs to be maintained below the level of the bladder to prevent reflux of urine into the urinary tract. Any loose anchors need to be removed and replaced to ensure that the catheter tubing does not get pulled on, as this could cause trauma to the urethra. However, the anchor needs to be placed on the upper thigh, not the lower leg. Therefore, option 3 is the action that requires a need for further teaching.

A student nurse is working with a preceptor to administer an enema to the patient. Which action by the student prompts intervention and redirection by the preceptor? a. Water-soluble lubricant is applied to the end of the enema tubing. b. The enema tubing is primed with solution that has been warmed. c. The patient is positioned comfortably in the right side-lying Sims position. d. The patient's bedpan is put at the bedside in preparation for use.

c. The patient is positioned comfortably in the right side-lying Sims position. The patient should be placed in the left side-lying Sims position prior to enema administration so that the enema fluid will readily flow through the colon without having to go uphill. The other actions demonstrate correct enema administration steps.

The nurse is caring for a patient who is constipated and has not had a bowel movement for 3 days. The nurse performs a rectal examination and finds hard dry stool in the rectum. What is the best option to help the patient have a bowel movement? a. Glass of warmed prune juice b. Loperamide (Imodium) c. Oral fiber supplement d. An oil retention enema

d. An oil retention enema The patient with hard, dry stool in the rectum will benefit from an oil retention enema because it will soften the stool and make it easier to pass. Imodium is an antidiarrheal that will worsen the constipation. An oral fiber supplement and prune juice should be given after the patient has a bowel movement to prevent constipation from recurring.

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse would take which immediate action? a. Withdraw the catheter slightly and reinflate the balloon. b. Remove the catheter, and reinsert a new one that is 1 size smaller. c. Finish inflating the balloon; the discomfort is normal and temporary. d. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

d. Aspirate the fluid, advance the catheter farther, and reinflate the balloon. If the balloon is malpositioned in the urethra, balloon inflation could cause trauma and pain. If this occurs, the fluid needs to be aspirated and the catheter inserted a little farther to move the balloon past the neck of the urethra into the bladder. The catheter would not be withdrawn slightly because this will worsen the problem. There is no need to remove the catheter and reinsert a smaller one. The balloon would not continue to be inflated because the pain is not normal and will not go away.

The nurse is caring for a patient who has not had a bowel movement for 2 days. Which is the priority nursing intervention for this patient? a. Obtain an order to administer a soap suds cleansing enema. b. Teach the patient how to use the Valsalva maneuver. c. Discontinue medications that can cause constipation. d. Assess the patient's usual pattern of bowel movements.

d. Assess the patient's usual pattern of bowel movements. The nurse should assess the patient's usual pattern of bowel movements to determine if it is normal for the patient to have a bowel movement every 2 to 3 days. Patients should be taught not to use the Valsalva maneuver because it can lead to bradycardia or death. Medications are not independently discontinued by the nurse and this would require a conversation with the provider.

A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should nurse Bea include in a bladder retraining program? a. Establishing a predetermined fluid intake pattern for the client b. Encouraging the client to increase the time between voidings c. Restricting fluid intake to reduce the need to void d. Assessing present elimination patterns

d. Assessing present elimination patterns The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.

The nurse is caring for a patient with a history of dementia who is incontinent of stool because of the inability to communicate the need to defecate. What is the priority action of the nurse? a. Administer a daily laxative and take the patient to the toilet afterward. b. Digitally remove stool from the patient's rectum every other day. c. Insert a rectal tube to facilitate drainage of soft or liquid stool. d. Begin a prompted toileting program to facilitate bowel continence.

d. Begin a prompted toileting program to facilitate bowel continence. Patients who cannot communicate the need to use the toilet often benefit from a prompted toileting program in which the patient is brought to the toilet at the same times each day to promote urinary and bowel continence. A rectal tube should not be used. Digital removal of the impaction should be avoided whenever possible. Laxatives should be used only when necessary because continued use will lead to dependence.

The nurse is caring for a patient who is recovering from gastroenteritis. The nurse teaches the patient about dietary recommendations as the digestive system recovers. Which menu selection by the patient indicates that additional teaching is needed? a. Applesauce b. Orange Popsicle c. White toast d. Coffee with cream

d. Coffee with cream Coffee with cream should be avoided by patients recovering from gastroenteritis because milk proteins are difficult for the digestive system and caffeine increases peristalsis. Caffeine is also a diuretic, which can lead to continued dehydration.

Before enema administration, the nurse positions the client in a left lateral position. What is the rationale for using this position? a. It is more comfortable. b. It facilitates the passage of stool. c. It prevents a vasovagal response from occurring. d. It facilitates instillation of the enema solution into the colon.

d. It facilitates instillation of the enema solution into the colon. The sigmoid and descending colons are located on the left side. Therefore, the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colons. Acute flexion of the right leg allows for adequate exposure of the anus. The other options are incorrect.

The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse? a. Encourage oral fluid intake and administer a diuretic. b. Obtain a urine sample to test for culture and sensitivity. c. Calculate the patient's daily intake and output. d. Obtain an order to straight-catheterize the patient.

d. Obtain an order to straight-catheterize the patient. The patient who has not voided for 6 to 8 hours after urinary catheter removal and is complaining of suprapubic pain has acute urinary retention. The physician should be notified to obtain an order for straight catheterization to drain the bladder. A urine sample for culture and sensitivity is not ordered. Encouraging fluid intake and administering a diuretic will increase the amount of urine in the bladder and make the patient even more uncomfortable.

The nurse is caring for a patient who has urinary frequency. Which nursing diagnosis is the highest priority for this patient? a. Impaired urination r/t occasional incontinence b. Anxiety r/t living alone at home with nocturia c. Risk for infection r/t urine contact with perineal area skin d. Risk for fall-related injury r/t hurried trips to the bathroom during the day and night

d. Risk for fall-related injury r/t hurried trips to the bathroom during the day and night Risk for falls is the highest priority diagnosis for this patient because rushing to the bathroom can lead to loss of balance and serious injury. Walking to the bathroom at night is even more dangerous because of low lighting conditions and sleepiness. The other nursing diagnosis may be appropriate but not higher than the injury risk.

The nurse is inserting an indwelling urinary catheter in a client. As the nurse begins to inflate the balloon, the client starts to complain of pain. Which action would the nurse take? a. Continue to inflate the balloon. b. Deflate the balloon, slightly withdraw the catheter, and attempt to reinflate the balloon. c. Deflate the balloon, completely withdraw the catheter, and end the procedure to notify the primary health care provider. d. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.

d. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon. The client's pain during inflation of the balloon may be related to the urinary catheter tip being located in the urethra and not the bladder. If the client begins to complain of pain with the inflation of an indwelling urinary catheter balloon, the nurse would allow the fluid injected into the balloon to drain back into the syringe attached to the balloon inflation port. Then, the nurse would advance the catheter farther into the urethra to the bladder, and then attempt to inflate the balloon. Therefore, option 4 is correct.

The preceptor is watching a nursing student care for a male patient who requires a condom catheter. Which action by the nursing student indicates that the procedure is performed correctly? a. Sterile gloves are donned before touching the catheter. b. Adhesive tape is applied securely around the base of the penis. c. Water-soluble lubricant is applied to the end of the catheter. d. The foreskin is returned to its natural position before the catheter is applied.

d. The foreskin is returned to its natural position before the catheter is applied. The patient's penis should be cleaned with soap and water with the foreskin retracted prior to condom catheter application. The foreskin should then be returned to its natural position before the catheter is applied. Adhesive tape should never be applied around the base of the penis because circulation may be compromised. Sterile gloves and lubricant are not needed.