NEW BDN 205 - Wk 5

Maya Avila is a​ 52-year-old woman who lives with her​ husband, Pablo, in a restored farmhouse. Pablo is a​ self-employed plumber. They raise heirloom​ tomatoes, which they sell to local restaurants. To make ends​ meet, Mrs. Avila works in a clothing store in a nearby city as a personal shopper.​ Since​ college, Mrs. Avila has been having problems with constipation. Her only medication has been psyllium one tablespoon three times daily. She and her husband do not have biological​ children, but they have been foster parents for many​ children, and still keep in touch with several of them.​ Three days​ ago, Mrs. Avila developed a complete bowel obstruction. She was admitted to the hospital for an emergency bowel resection. The surgeon constructed a permanent ileostomy. The bowel resection was performed on an unprepared bowel. The experienced surgical team was able to avoid spillage of intestinal contents into the peritoneal cavity.​ As the hospital discharge planning​ nurse, you read Mrs. Avila​'s chart to prepare yourself to assist her smooth transition from hospital to home.When you go into Mrs. Avila​'s hospital room to assess her​ condition, you will be evaluating the appearance and functioning of her ileostomy stoma. Where is her stoma​ located?

Distal end of the small intestine Rationale: An ileostomy stoma is at the​ distal, not​ proximal, end of the small intestine. A sigmoidostomy stoma is at the distal end of the large intestine. There is no intersection of the ascending and descending​ colon; the transverse colon connects them.

After reviewing Mr. Ellis' diagnostic test results, the nurse consults with the HCP and receives a prescription for a new antibiotic. Since Mr. Ellis' creatinine level is elevated. The nurse is concerned about which problem in administering the medication?

Drug toxicity due to reduced drug excretion. Rationale: An elevated creatinine level reflects a problem with the kidneys. If the kidneys are unable to excrete drug molecules efficiently, the drug will remain in the body for a prolonged period of time, which may result in drug toxicity.

The nurse encourages Janelle to increase her daily oral fluid intake to 2 liters of fluid for the next few days. The nurse advises Janelle to drink a minimum of how many 8-ounce cups of fluid daily?

Eight to nine Rationale: One 8-ounce cup contains 240 mL (8 x 30 mL/ounce) Two liters = 2,000 mL 2,000 mL/240 mL = 8.33 cups/day.

The RN encourages the student nurse to perform the irrigation. The student prepares the solution, applies gloves, clamps the distal tubing, and begins to clean the specimen port on the drainage tubing. What action should the nurse take?

Encourage the student nurse to continue, maintaining aseptic technique. Rationale: The student nurse is performing the procedure correctly. Irrigation may also be performed by opening the connection between the catheter and the drainage tubing, but opening that connection increases the risk of contamination.

Mr. Ellis' hematuria continues. Two hours later, he becomes restless and appears to be in pain. The nurse observes that there has been no urinary output during the last 2 hours. Which assessment should the nurse complete first?

Evaluate the urinary drainage tubing. Rationale: The client has had no urine output in 2 hours, he has been experiencing blood clots in his urine, and he is in obvious discomfort. The nurse should first consider that the catheter tubing is obstructed and assess for kinks or pressure on the tubing that might cause an obstruction. The nurse should also note the presence of any observable blood clots, which can also obstruct urine flow. This simple, noninvasive measure could easily identify and immediately resolve the client's

Janelle responds, "I did everything my HCP told me to do. The surgery must have caused this. They must have made a mistake." Which explanation by the nurse is accurate?

Explain to the client the multiple factors that can decrease peristalsis postoperatively, even when the desired surgical outcome is achieved. Rationale: Constipation secondary to decreased peristalsis postoperatively is not considered a poor surgical outcome. Multiple factors surrounding abdominal surgery can lead to decreased peristalsis

The nurse notes that the medication dosage is in the safe range for elderly clients, which is to be administered by IV every 12 hours. The nurse recognizes that the frequency of drug administration is based on which characteristic of the medication?

Half-life Rationale: Half-life describes the length of time required to reduce a drug level to one half of its initial value. Drugs with shorter half-lives will have to be given more frequently than those with longer half-lives.

The remainder of Janelle's surgical recovery is uneventful. She continues to drink plenty of fluids, increases her activity, and has regular bowel movements. Janelle eats a regular diet with no restrictions and asks the nurse about foods that promote bowel regularity. Which type of diet should the nurse recommend?

High fiber Rationale: High fiber foods accelerate the passage of food through the intestines, which is important for bowel regularity.

The nurse auscultates for Janelle's bowel sounds and hears faint gurgling sounds after 3 minutes. Which assessment finding should the nurse document?

Hypoactive bowel sounds Rationale: Normally, bowel sounds are heard 5 to 35 times per minute. When bowel sounds are heard only after listening for 3 minutes, they are recorded as hypoactive.

Since Mr. Ellis now voids spontaneously without recognizing the need to void, how should the nurse document his current urinary pattern in the medical chart?

Incontinence

Incontinence

Incontinence is the involuntary loss of urine. In the case of this client, it may be the result of neurologic impairment secondary to the stroke.

The nurse observes that Janelle's abdomen is firm and distended. The nurse performs an abdominal assessment. Which sequence should the nurse perform the abdominal assessment?

Inspection, auscultation, percussion, palpation. Rationale: Percussion and palpation can alter abdominal findings, so inspection and auscultation are indicated prior to percussion and palpation.

Which non-pharmacologic treatment is appropriate for treating urinary retention?

Intermittent catheterization Rationale: Intermittent catheterization is a treatment for urinary retention. Habit training, Kegel exercise, and urinary containment exercises are taught to clients to reduce urinary incontinence.

Mr. Ellis voids after the catheter is removed and he is discharged from the acute care facility and transferred to the long-term care facility. Since he no longer has an IV, the prescription for his antibiotic is changed to an oral medication. Mr. Ellis has some difficulty swallowing (dysphagia), and the nurse is considering the best technique to help Mr. Ellis swallow the medication. Before deciding to open the capsule and mix it with food, what will the nurse need to determine?

Is the medication in extended-release form? Rationale: An extended-release medication is formulated for gradual absorption in the body. Opening or crushing the medication will adversely affect this action.

Why is incontinence a risk factor for low self-esteem and social isolation?

It is considered socially unacceptable Rationale: Urinary incontinence is considered socially unacceptable. Therefore, it an be physically and emotionally distressing. Often times the client is embarrassed about dribbling or having an accident, and may therefore restrict normal activities.

Which treatment is useful in the therapeutic management of bowel ​incontinence?

Kegel exercise Exercises to improve sphincter and pelvic floor muscle tone​ (Kegel exercises) may be of​ long-term benefit. Treatment of bowel incontinence depends on the underlying cause of the incontinence. Medications to control bowel incontinence include loperamide​ (Imodium) and bismuth subsalicylate​ (Kaopectate, Pepto-Bismol), not cathartic medications. Digital stimulation of the rectum is used to treat fecal impaction. Regular exercise will improve sphincter and pelvic floor muscle tone.

A client with renal failure is prescribed hemodialysis by the health care provider. Which independent nursing intervention is the priority for this client?

Maintaining aseptic technique Rationale: The nurse caring for a client who is prescribed hemodialysis must maintain aseptic technique. Hemodialysis increases the client's risk of infection. While the other choices are independent nursing actions, they are not the priority for this client.

The daughter of a wheelchair-bound older client is concerned because her mother has been experiencing urinary incontinence. Which statement should the nurse use to explain the condition to the daughter?

Mobility issues may cause urinary incontinence? Rationale: Both mobility and neurological issues may cause urinary incontinence. The other explanations do not address the daughter's concern regarding her mother's urinary incontinence.

The nurse explains to Janelle that she has developed constipation, probably as the result of a number of factors. Janelle has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 mL. The nurse explains risk factors that can contribute to constipation. Which postoperative medication is most likely to contribute to constipation?

Morphine sulfate, an opioid analgesic. Rationale: The most common adverse effect of opioid analgesics is constipation.

When Mr. Ellis is calm, the nurse assigns the UAP to help him into dry clothing. Several minutes later, the nurse walks down the hall and sees the UAP in the room changing Mr. Ellis' clothes. The nurse enters the room and assesses the situation. Which aspect of the situation requires the nurse's most immediate intervention?

Mr. Ellis' room door is open to the hallway. Rationale: This is disrespectful, demeaning, and an invasion of the client's privacy. It should be corrected immediately.

Mr. and Mrs. Avila offer you some of the "goodies" which friends brought to the hospital. The gifts include both items Mrs. Avila can have on her​ low-residue diet, and some items she cannot have. They placed a​ post-it with a red "X" on the ones she can't have. "We had fun doing ​that,"Mr. Avila tells you.​ You return to the nurse​'s​ station to document your nursing care. What is the most important fact for you to record in Mrs. Avila​'s medical​ record?

Mr.​ Avila, rather than his​ wife, performed the change of the ostomy pouch. Rationale: It is important to document that Mr.​ Avila, rather than his​ wife, performed the change of ostomy pouch. You have​ identified, and need to​ document, that Mrs. Avila might have a​ self-care deficit. That fact is more important to record than her knowing about her diet or stomal​ appearance, or learning when her pouch needs to be emptied or changed.

The nurse is unable to resolve the catheter obstruction using noninvasive measures and notifies the healthcare provider (HCP), who prescribes bladder irrigation to dislodge any blood clots obstructing the urine flow. The nurse anticipates that the prescription will include the use of which sterile solution to irrigate the catheter?

Normal saline. Rationale: An isotonic saline is a sterile normal solution that can be used for internal organ irrigations such as the bladder or stomach.

Mr. Ellis' confusion decreases, and 12 hours later the nurse is able to remove the wrist restraints. By the third postoperative day, no further hematuria or blood clots are observed in Mr. Ellis' urine. However, the nurse does observe that the urine has developed a cloudy appearance. Which action should the nurse implement?

Obtain a sterile urine specimen. Rationale: Urine develops a cloudy appearance when a urinary tract infection has developed. A sterile specimen is needed to detect an infection and identify microorganisms.

The nurse consults with the pharmacist, who determines that the capsule can be opened and mixed with a food that the client likes. Which technique should the nurse use?

Open the capsule and mix the medication with pudding. Rationale: Opening the capsule allows the client to receive the medication enclosed. Pudding is a safe consistency for most clients with dysphagia, who typically have more difficulty swallowing liquids than semi-soft foods.

The nurse uses the hospital breakfast menu as a teaching tool. Which breakfast selection by Janelle indicates that she understands teaching about dietary measures to promote bowel regularity?

Orange juice and oatmeal with raisins. Rationale: Whole grain cereals and fruits are good sources of fiber, which is beneficial to bowel regularity.

The nurse is caring for a client at risk for urinary retention. Which clinical manifestations does the nurse document during the nursing assessment to support diagnosis?

Overflow voiding Rationale: The nurse should monitor the client for overflow voiding. This manifestation associated with urinary retention. Cool, clammy skin, nausea and vomiting, and hematuria are not manifestations associated with urinary retention.

What is the cause of stress incontinence?

Pelvic muscle relaxation and a weak urethra and surrounding tissues cause decreased urethral resistance. Rationale: Stress incontinence occurs when the pelvic muscle relaxes and a weak urethra and surrounding tissues cause decreased urethral resistance. Urge incontinence is when an overactive detrusor muscle increases bladder pressure. Overflow incontinence is when the lack of normal detrusor muscle function causes bladder overfilling and increased bladder pressure. Functional incontinence occurs when the client is unable to respond to the need to urinate.

During a checkup, a pregnant client reports urinary incontinence. Which teaching topic is the most appropriate for the nurse to provide for this client?

Performing Kegel exercises Rationale: Kegel exercises may help pregnant women maintain urinary muscle strength and prevent incontinence. Alcohol should be avoided during pregnancy, but abstinence will not address the concern of incontinence. Consuming fiber is an appropriate topic for a client experiencing constipation. Increasing fluid intake will not help a client with urinary incontinence.

A female client reports intense thirst, weight loss, and a large volume of urine when voiding. Which condition should the nurse consider that the client is experiencing?

Polyuria Rationale: Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss. The assessment findings do not describe enuresis, urgency, or dysuria.

A client diagnosed with bowel obstruction is scheduled for surgical resection of the bowel. Which nursing action is the most appropriate for this client?

Prepare needed preoperative instructions The client who needs surgical resection of the bowel will need preoperative instructions, and it is the nurse's role to provide them. Instructions on care and cleaning of the ostomy pouch will depend on whether the resection requires one. Enemas are used for impactions, not obstructions. Chemotherapy and radiation therapy are used for bowel cancer.

The nurse reviews factors that may impact catheter insertion with the student nurse. Which physiologic change that commonly occurs in elderly males may affect insertion of the catheter?

Prostate gland enlargement. Rationale: The prostate gland often begins to enlarge after a male client reaches the age of 40, making urethral catheterization more difficult if the gland compresses the urethra.

An older male client is experiencing dysuria and urinary retention. Which condition in the client's history may be causing these clinical manifestations?

Prostatic hyperplasia Learning objective: Compare common alterations across the lifespan, concepts related to elimination, and prevention. Rationale: Prostatic hyperplasia (enlargement of the prostate) can cause urinary retention, dribbling at the end of urination, incontinence, and nocturnal enuresis. Renal failure does not cause dysuria or retention. Polyuria is a term that describes an increase in urination. Anuria is the absence of urination.

Urinalysis results are as follows: pH: 8.5S pecific gravity: 1.015 Protein: none Glucose: none WBCs: 8 RBCs: 2 Bacteria: present Based on the urinalysis results, the HCP prescribes a broad-spectrum antibiotic. After 24 hours of receiving the antibiotic, Mr. Ellis' condition has not improved. What additional nursing intervention should the nurse implement?

Provide a glass of cranberry juice daily. Rationale: The pH of the client's urine is elevated, indicating alkaline urine. Cranberry juice is believed to increase the acidity of urine, providing a less desirable environment for bacterial growth.

Which if the following is the purpose of hemodialysis and peritoneal dialysis?

Provide blood filtration Rationale: Hemodialysis and peritoneal dialysis filter the blood and are used in the treatment of renal failure. Aseptic technique must be used when performing both types of dialysis. Dialysis is not used to administer cholinergic medication or to provide digital stimulation.

When administering the rectal suppository, the nurse asks Janelle to take several slow, deep breaths. What is the rationale for this instruction?

Relax the anal sphincter and reduce discomfort. Rationale: Deep breathing promotes relaxation of the anal sphincter, thereby reducing discomfort when the suppository is inserted.

To help manage Mr. Ellis' incontinence, the nurse initiates a bladder training program. Which instruction should the nurse provide to the unlicensed assistive personnel (UAP) who will be helping care for Mr. Ellis?

Remind the client to void every 2 hours while awake and to call for assistance to the bathroom. Rationale: A toileting schedule is an effective means to retrain the bladder. Bladder training should start with voiding every 2 hours in the daytime and every 4 hours at night and then be adapted to the individual needs. The call bell should be near the client so that he can ring the bell for assistance to prevent the risk of falling.

A client is admitted to a clinic with urinary retention caused by a functional problem. Which option is the likely cause of this client's condition?

Repeated urinary tract infections Learning objective: Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale: Repeated urinary tract infections lead to scarring of structure, which is a functional problem associated with urinary retention. Benign prostatic hypertrophy and fecal impaction are the causes of an obstruction that will lead to urinary retention. Anticholinergic medications may cause retention, but this is not a functional problem. Once the medication is stopped the retention resolves.

Before administering the rectal suppository, how should the client be positioned?

Sim's Rationale: The client should be in Sim's position, on the left side, with the knee flexed.

A female client is experiencing problems with urinary elimination. After an initial assessment interview, the nurse performs a physical examination. Which specific assessment will the nurse include?

Skin assessment Learning objective: Identify procedures used to determine elimination status across the lifespan. Rationale: A focused nursing assessment of the urinary system includes a skin assessment, an abdominal assessment, a urinary meatus assessment, a kidney assessment, and a bladder assessment. Dietary, perineal, and inguinal area assessments would be appropriate for a client experiencing an alteration in bowel function.

During the catheter irrigation, the nurse observes that Mr. Ellis is still confused and attempts to pull at his urinary catheter, his IV, and his nasal cannula. The nurse considers the use of wrist restraints on the basis of which rationale?

The client is at risk for self-injury. Rationale: Risk of self-injury is a reasonable rationale for the use of physical restraints. However, all other safety measures should be attempted before physically restraining a client.

The nurse explains to Janelle that she has developed constipation, probably as the result of a number of factors. Janelle has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 mL. The nurse explains risk factors that can contribute to constipation. What impact does this fluid intake have on Janelle's bowel patterns?

This inadequate fluid intake has contributed to her constipation. Rationale: An adult needs 1,400 to 2,000 mL of fluid daily to prevent hardening of the stool.

Nocturia

This specifically refers to voiding frequently at night. The incidence of nocturia increases greatly in the older male client who has an enlarged prostate. It may also indicate an inability to concentrate urine because of poor blood flow to the kidneys.

The nurse is providing care to a client with urinary incontinence who has been prescribed bladder training behavior modification. Which goal of therapy does the nurse include in the teaching session with the client?

To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times. Rationale: To gradually increase the bladder capacity by increasing the intervals between voiding and resisting the urge to void between scheduled times. Scheduled voiding is toileting at regular intervals. Kegel exercise is a technique that is done to identify the pelvic muscles for pelvic floor muscle.

What is the therapeutic purpose of medications, such as oxybutynin (Ditropan, Ditropan XL) and Tolterodine (Detrol, Detrol LA)?

To increase bladder capacity Rationale: Oxybutynin (Ditropan, Ditropan XL) and Tolterodine (Detrol, Detrol LA) are medications that are used to increase bladder capacity. Alpha-blockers and alpha reductase inhibitors are used to treat men with BPH. Impramine (Tofranil) is used to contract the smooth muscles of the bladder neck, and reduce mild episodes of stress incontinence caused by postmenopausal atrophic vaginitis.

A client with urinary incontinence is scheduled for urodynamic testing. The client's family asks the nurse what this test is for. Which response by the nurse is the most appropriate?

To measure bladder strength and urinary sphincter. Learning objective: Identify collaborative therapies used by interdisciplinary teams. Rationale: Urodynamic testing measures bladder strength and urinary sphincter health. Cystometrography is a diagnostic test done to evaluate detrusor muscle function. A cystoscopy identifies structural disorders contributing to incontinence. Postvoiding residual volume determines how completely the bladder empties with voiding.

To encourage voiding, the RN instructs the UAP to perform what intervention?

Turn on the tap so water is running when the client attempts to void. Rationale: Running water often stimulates the urge to void, as does placing the client's hands in warm water.

A 74-year-old male client is experiencing urinary retention. Which diagnostic test does the nurse anticipate will be ordered for this client?

Ultrasonic bladder scans Rationale: Ultrasonic bladder scans are used to evaluate bladder emptying and to examine for residual urine. While cystoscopy, renal ultrasound, and urinalysis are often prescribed for clients with alterations in urinary function, these tests will not diagnose the cause of the urinary retention the client is experiencing.

The nurse reviews the medical chart for a client who is experiencing urinary incontinence. The healthcare provider's admission assessment identifies that the incontinence is relation to an overactive detrusor muscle. Based on the provider's note, which type of urinary incontinence is the client experiencing?

Urge Rationale: Urge incontinence is related to an overactive detrusor muscle, which increases bladder pressure. Stress incontinence is related to pelvic muscle relaxation and a weak urethra and surrounding tissues, which cause decreased urethral resistance. Overflow incontinence is related to a lack of normal detrusor muscle function, which causes the bladder to overfill and increases bladder pressure. Functional incontinence is related to the inability to respond to the need to urinate.

The nurse is reviewing the urinalysis test results conducted on Shanice Evans, a 29-year-old female. The report states that Shanice's urine appeared cloudy or hazy. Based on the urinalysis, which diagnosis does the nurse anticipate?

Urinary tract infection (UTI) Rationale: Hazy or cloudy urine indicates the presence of bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid, spermatozoa, or urates, which can indicate a urinary tract infection (UTI). Concentrated or dark urine is found with dehydration and fever. Cirrhosis of the liver and hyperglycemia do not cause the urine to appear cloudy or hazy.

Which diagnostic test result would make the nurse concerned that the client is at risk for sepsis?

Urine culture shows resistance to the prescribed antibiotic. Rationale: If the microorganisms causing the urinary tract infection are resistant to the prescribed antibiotic, the antibiotic is ineffective, and the client is at risk for sepsis, or generalized infection.

Mr. Ellis is admitted to the acute care facility for minor surgery. His preoperative prescriptions include the insertion of an indwelling urinary catheter. A student nurse is assigned to care for Mr. Ellis. The nursing instructor asks the student nurse to prepare to insert the indwelling catheter under supervision. What is the first step in the proper placement of an indwelling urinary catheter for a male client?

Wash perineal area with soap and water. Rationale: The student nurse should first wash the entire perineal area with soap and water before applying antiseptic or lubricant.

Mrs. Avila​'s surgeon has signed her discharge​ orders, and the couple is eager to get back home. Which home consultation would most benefit Mr. and Mrs.​ Avila?

Wound ostomy continence nurse​ (WOCN) Rationale: Once at​ home, Mr. and Mrs. Avila would most benefit from a visit by a wound ostomy continence nurse​ (WOCN). That nurse could help Mrs. Avila become more comfortable with​ self-care of her ileostomy. She does not need the help of a registered​ dietitian, an occupational​ therapist, or a physical therapist.

After reviewing Mrs. Avila​'s ​chart, you go to her room. Mr. and Mrs. Avila are holding hands when you introduce yourself as the discharge planning nurse. When he hears the word "​discharge". Mr. Avila shakes his head. "She's not ready to go home. Her skin opening is still very red and very swollen." What is your best response to Mr.​ Avila?

​"It is normal for stomal swelling to take 2 to 3 weeks to go down. Sometimes it can take up to 6​ weeks." Rationale: Mrs. Avila​'s stomal swelling will not be resolved before​ discharge, so the Avilas should not expect that to happen. By telling them what is​ normal, you respond to Mr. Avila​'s concerns and set their expectations for Mrs. Avila​'s recovery. You should not dismiss Mr. Avila​'s concern about swelling or redness by telling him that you are a better observer or that he is worrying unnecessarily.

The nurse is providing care to a client who is prescribed a complete decompression of bladder using intermittent catheterization. Which explanation about this procedure to the family is the most appropriate?

"A non-pharmacologic therapy for urinary retention." Rationale: Complete decompression of bladder using intermittent catheterization or an indwelling catheter is a non-pharmacologic therapy for urinary retention. The postvoiding insertion of a catheter to determine the volume of urine retained in the bladder is used to determine how completely the bladder empties with voiding. Uroflowmetry is used to evaluate voiding patterns. Urodynamic testing measures bladder strength and urinary sphincter health.

The mother of a 2-month-old infant is concerned that her son defecates too frequently. Which response by the nurse addresses this mother's concern?

"Frequent bowel movements can occur with breastfeeding." Learning objective: Understand the physiology of elimination across the lifespan. Rationale: Frequent bowel movements often occur with breastfeeding; therefore, this response is the most appropriate. There is no indication that the infant is losing weight. Control of defecation is not expected at 2 months of age. While feces that contain less water may be difficult to pass, the infant is not experiencing hard stools.

The nurse explains to Janelle that she has developed constipation, probably as the result of a number of factors. Janelle has not been taking oral fluids well, but she has been receiving IV fluids. Her total fluid intake for the previous 24 hours was 1,000 mL. The nurse explains risk factors that can contribute to constipation. What other questions should the nurse ask Janelle?

"How often do you get out of bed and walk?" Rationale: Immobility is a major risk factor for constipation.

The nurse is providing discharge education to a client diagnosed with urinary incontinence. Which client statement indicated the need for further education regarding preventative methods for urinary incontinence?

"I have switched to a lower-fiber diet." Learning objective: Apply the nursing process to provide culturally competent care across the lifespan. Rationale: A low-fiber diet is not indicated as a preventative method of decreasing urinary incontinence. The other client statements indicate an understanding of the teaching session.

When receiving the verbal prescription over the telephone, the nurse repeats the prescription back to the HCP, who sounds angry and shouts, "Are you questioning my prescription?" Which approach by the nurse is the best response to the angry HCP?

"I want to ensure that I transcribe this prescription correctly to avoid error." Rationale: This assertive response teaches the HCP the purpose of repeating back verbal prescriptions.

The mother of 2-month-old Vivienne Spinelli is concerned about the frequency of her infant's bowel movements. Which response by the nurse will address the mother's concern?

"Infant bowel movement patterns change at this age." Rationale: The infant's deification pattern changes at the age of 1 to 2 months, but it is not similar to adult habits. Infants may have from one or more bowel movements per day to one bowel movement every 1-2 weeks. Breast-fed infants usually have a higher frequency of bowel movements and formula-fed infants are more prone to constipation. Infants cannot control deification at 2 months, and pass meconium only in the first day of life.

Janelle tells the nurse, "I hate hospitals because nobody ever tells you what's happening, and you end up with all these things going wrong." Which response by the nurse will encourage continued verbalization by the client?

"It sounds as if you have had another experience that did not go well." Rationale: The nurse's response validates Janelle's feelings, which will encourage Janelle to verbalize further.

Mr. Avila accepts your explanation of the ​stoma's color and normal swelling. He asks another question. "What about the fact that when my wife touches the skin​ opening, some blood gets on her ​fingers?" You explain that some slight bleeding can happen​ initially, but that it will not continue. What statement by Mr. Avila suggests that he understands your​ explanation?

"My wife appears to be healing​ normally." Rationale: Mr. Avila has understood your explanation when he accepts the fact that the appearance of a small amount of bleeding is consistent with normal healing. After hearing your​ explanation, the couple should not worry about Mrs. Avila​'s touching the​ stoma, losing more​ blood, or being monitored more frequently.

The nurse explains to Janelle that her HCP has prescribed two medications: a one-time dose of bisacodyl rectal suppository and docusate sodium 100 mg PO daily. The nurse explains that the bisacodyl suppository will have a laxative effect. How will the nurse explain to Janelle the action of the laxative?

"Soften the stool, distend the rectum to expel the stool." Rationale: Laxatives soften the stool and stimulate the rectal mucosa to produce soft or liquid stool.

While the nurse is completing the assessment, Janelle begins to cry and laments, "I just knew something would go wrong." How should the nurse respond?

"Tell me what is making you feel so upset." Rationale: This open-ended statement encourages the client to express further concerns and fears.

A nurse is caring for 75-year-old Reginald Gibbs, who believes he urinated too frequently. Which response by the nurse is the most appropriate?

"The average person urinated approximately five or six times per day." Rationale: Although patterns of urination are highly individual, most people void about five or six times a day. This response will provide Mr. Gibbs with a guideline to determine whether he is really urinating too frequently. The other responses do not address urinary frequency.

Following an episode of incontinence, the nurse washes the client's perineal area with mild soap and water and applies a water-repellent ointment to the skin. Mr. Ellis' wife is present and the nurse uses this opportunity to educate her about proper skin care to prevent breakdown. Which of the following statements made by Mrs. Ellis indicates that teaching has been effective?

"Washing the area with mild soap and water followed by ointment can help to protect my husband's skin." Rationale: Mild soap and warm water should be used to cleanse the skin followed by a protective ointment. These water-repellent ointments help protect the skin from the acidic effects of urine.

At 5 feet 10 inches and 320 pounds, Emilio Ginzales has been advised to lose weight for his overall health and to help with a recent problem of incontinence. Mr. Gonzales asks how losing weight will eliminate his incontinence. Which explanation by the nurse is the most appropriate?

"Weight loss can reduce stress incontinence causes by increases pressure on the bladder as a result of obesity." Rationale: Obesity is a risk factor for urinary incontinence, especially stress incontinence. This is most likely because of the excess force placed on the bladder. Not all clients with diabetes are obese and not all obese clients have diabetes. Reflex incontinence causes the bladder to empty at a predictable volume. Overflow incontinence is the lack of normal detrusor muscle function causing bladder overfilling and increased bladder pressure.

The nurse is providing care to a client diagnosed with urinary incontinence. Which client statements support the nursing diagnosis of social isolation?

-"I am so embarrassed when I wet myself. Even when I use absorbent pads, I feel like I smell of urine." -"When I leave home, I worry that I can't find a bathroom in time." Learning objective: Apply the nursing process to provide culturally competent care across the lifespan. Rationale: Embarrassment and oder and the fear of not being able to find a bathroom in time can lead to social isolation. Seeking out and using absorbent products, use of odor eliminators, and scheduling diuretics to provide adequate time to make frequent trips to the bathroom are coping strategies that a client may use to continue to participate in normal social activities.

Which factor leads to constipation and fecal​ impaction?

-Antacids -Psychogenic factors -Tumor Antacids containing aluminum or calcium​ salts, narcotics, many​ antidepressants, some antihypertensive​ agents, tranquilizers,​ sedatives, diuretics, and iron salts can all cause constipation and fecal impaction. A tumor can cause acute or chronic constipation. Voluntary suppression of the urge to​ defecate; perceived need to defecate on​ schedule; and depression contribute to constipation and fecal impaction. A lack of exercise contributes to constipation and fecal impaction. Highly refined​ low-fiber foods and inadequate fluid intake contribute to constipation and fecal impaction.

Mr. Avila shows that he can smoothly replace his​ wife's ileostomy pouch. The next topic you want to review with the couple is Mrs. Avila​'s prescribed​ low-residue diet. Which foods will you reinforce as appropriate for Mrs. Avila to​ eat?

-Apple sauce -Canned green beans Rationale: Mrs. Avila is on a​ low-residue diet to reduce irritation to her healing stoma. Canned green beans and applesauce are​ appropriate, but roughage would pose a problem. She should avoid​ whole-grain breads and​ cereal, raw​ carrots, and brown rice.

Janelle has moderate results from the enema and tolerates the procedure well but states she feels a second enema would be beneficial. While talking with Janelle, the nurse receives report from the UAP that another client is vomiting. The nurse tells Janelle she will return as soon as she deals with the other client's problem. What task can the nurse delegate to the UAP?

-Assist the client who vomited with mouth care after the RN administers an antiemetic. -Assist the client with a bed bath and hygiene if required. Rationale: Hygiene and comfort care are both within the UAP's scope of practice. Rationale: Hygiene and comfort care are both within the UAP's scope of practice.

Which non-pharmacologic treatments are appropriate in the treatment of functional incontinence?

-Assistive devices -Absorbent pads/diapers Rationale: Absorbent pads/diapers and assistive devices (e.g., commode, raised toilet seat) are non-pharmacologic treatments for functional incontinence. A pessary and Kegel exercise are used to treat stress incontinence. Catheterization is used to treat urinary retention.

Which is the most important action for the nurse to perform when assessing bowel sounds?

-Begin auscultation in the right lower quadrant. -Listen for up to 5 minutes when auscultating for bowel sounds. Rationale: The nurse should auscultate in the right lower quadrant, and then proceed to the other quadrants. Rationale: The nurse must listen for up to 5 minutes before determining what type of bowel sounds are present.

When admitting an older adult client to a community clinic. The nurse recognizes which of the following factors places a client at risk of constipation?

-Chronic laxative use -History of diverticulosis -Belief in the necessity of a daily bowel movement -Suppressing the urge to defecate Learning Objective: Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale: Ignoring the urge to defecate causes the muscles and mucosa in the rectal area to become insensitive to the presence of stool, which becomes more difficult to expel. Diverticulosis is seen in people with low fiber intake leading to hard bowel movements. High levels of dietary fiber and high fluid intake decrease the chance of constipation.Belief in the need for a daily bowel movement can cause the overuse of laxatives. Overuse of laxatives and the dilation of the bowel with loss of smooth muscle tone in the colon can cause constipation.

Which assessment is appropriate or a client experiencing alterations in bowel function?

-Client interview -Abdominal assessment -Inguinal area assessment Rationale: Client interview, abdominal assessment, and inguinal area assessment are used to assess clients experiencing alterations in bowel function. A skin assessment and renal assessment are more appropriate for alterations in urinary elimination.

The nurse is caring for a child experiencing altered bowel elimination. What collaborative therapy could be implemented with a child who has​ encopresis?

-Collaboration with school nurses and teachers -Psychological treatment -Behavioral modification -Pharmacologic treatment of constipation Rationale: Appropriate therapies include psychological​ treatment, collaboration with school nurses and​ teachers, pharmacologic treatment of​ constipation, a​ high- fiber​ diet, and behavioral modification. A client experiencing encopresis should drink 6-8 glasses of fluid per day.

A nurse is admitting a child to the pediatric unit with altered bowel elimination. What cause can lead to encopresis that the nurse needs to explore​ further?

-Diet -Fecal impaction -Anger issues -Stress Rationale: Encopresis is characterized by recurrent soiling or passage of stool at inappropriate times by a child who should have achieved bowel continence. The causes of encopresis are stress related to environmental​ changes; anger​ issues; diet; and fecal impaction. Premature birth is not a cause of encopresis.

When caring for an older adult​ client, what collaborative therapy is utilized in the management of fecal​ impaction?

-Digital removal of impaction -Bowel training program Rationale: For clients with fecal​ impactions, bowel training programs may be helpful. Digital removal of the impaction can be accomplished with administration of an oil retention enema 30 minutes prior to the​ disimpaction, followed by cleansing enemas as indicated. The intake of hot​ drinks, not​ cold, just before defecation is helpful.​ High-residue foods will increase bulk in the colon.​ High-fiber content foods should be consumed.​ High-residue foods and decreased fluid intake will increase the amount of stool in the colon.

Mrs.​ Avila's ostomy pouch is leaking stool. You ask​ her, "Are you ready to show me that you can change the​ pouch?" "I'm too​ tired," she replies. Mr. Avila gestures to his wife.​ "I will take care of changing the pouch until Maya feels more like her old​ self." In what order will Mr. Avila follow the steps to change his​ wife's ostomy​ pouch, once it has been emptied and​ removed?

-Discard the pouch in a moisture proof bag. -Clean, rinse, and dry the stoma and the skin around it. -Measure the stoma and assess it's color and shape. Inspect the skin for problems. -Apply the skin prep and skin barrier paste. -Center the new pouch over the stoma, and press to adhere. Rationale: After the ostomy pouch is emptied and​ removed, Mr. Avila needs to discard it in a​ moisture-proof bag. Next he will​ clean, rinse, and dry the stoma and the skin around it. The next step is to measure the stoma and assess its color and shape. Then Mr. Avila should inspect his​ wife's skin for problems before applying skin prep and skin barrier paste.​ Finally, he should center the new pouch over the​ stoma, and press to adhere.

The nurse is providing education on measures to facilitate defecation to a client who has a history of constipation. Which suggestion does the nurse include when teaching the​ client?

-Eat high-fiber foods -Drink a glass of warm water before breakfast Rationale: Increasing water consumption is important to relieve constipation and promote defecation.​ However, the client should consume about 2500​ mL, not 1000 mL of fluid. A pureed diet does not provide adequate dietary fiber. Increasing dietary fiber will help promote defecation. Drinking a warm glass of water can stimulate peristalsis and facilitate defecation after food is eaten. It is not necessary to have a daily bowel movement. Taking laxatives frequently is contraindicated because it can make a client dependent on them. Taking excessive amounts of laxatives lessens the possibility of the client returning to a normal pattern of defecation. Eating​ high-fiber foods promotes peristalsis and bowel movements.

Which is a condition of involuntary urinary elimination?

-Enuresis -Incontinence Rationale: Two types of involuntary urinary elimination are enuresis and urinary incontinence. Enuresis is repeated involuntary urination in children old enough for bladder control. Urinary incontinence is involuntary leakage of urine or loss of bladder control. Oliguria and anuria are alterations in urinary elimination but are not considered involuntary. Impaction is a term that refers to an accumulation of dry fecal contents in the bowel that cannot be expelled.

The nurse is providing education to a community women's group regarding bowel elimination. Which risk factor should the nurse discuss with the group regarding the cause of fecal incontinence?

-History of radiation exposure -Psychological history -Obstetrical history -History of neurological diseases Learning Objective: Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale: Causes of fecal incontinence include neurological causes; local trauma; such inflammatory processes as radiation exposure; psychological causes; and other physiological factors. A history of urinary disease would not likely contribute to fecal incontinence.

You plan to refer Mrs. Avila to the local ostomy support group. To prepare her for hearing about the full range of challenges faced by people with different stomal​ locations, you plan to educate Mrs. Avila about stool formation along the colon. In what​ order, from least formed stool to most formed​ stool, should Mrs. Avila know about the different stomal​ locations?

-Ileostomy -Cecostomy -Ascending colostomy -Transverse colostomy -Descending colostomy -Sigmoidostomy Rationale: The location of the ostomy determines the characteristic of the stool. The large intestine or colon absorbs water from the fecal mass. So the longer stool is in the​ colon, the stool becomes more formed. The order of least formed to the most formed stool​ is: ileostomy,​ cecostomy, ascending​ colostomy, transverse​ colostomy, descending​ colostomy, sigmoidostomy.

When preparing education for a client with a history of constipation. What nonpharmacologic information should the nurse include?

-Implement a bowel training program -Eat raw fruits and vegetables -Maintain a regular exercise program Learning Objective: Identify collaborative therapies used by interdisciplinary teams. Rationale: Nonpharmacologic information that the nurse needs to educate the client about includes eating raw fruits and vegetables; maintaining a regular exercise program; and implementing a bowel training program. The client needs to drink 6-8 glasses of fluid per day to avoid constipation. Taking a bulk-forming laxative is a pharmacological intervention when managing constipation.

During a home visit, an older adult male client mentions that he has experienced an increase in the frequency of urination at night. Which condition relates to increased urinary elimination at night?

-Infection -Nocturia -Residual urine Learning objective: Understand the physiology of elimination across the lifespan Rationale: The client is experiencing nocturia, which is the need to urinate two or more times a night. Residual urine or infection may be causing the client to experience this condition. Alterations in the ability to recognize bladder fullness can lead to incontinence or retention. Oliguria is a decrease in urination, which is the opposite of what this client is experiencing.

Which specific instruction should a nurse provide to a client experiencing an alteration in bowel function?

-Instruction on Kegel exercises and biofeedback -Instruction on increased fluid and fiber intake Rationale: The nurse should educate the client on increased fluid and fiber intake, and the importance of Kegel exercises and biofeedback techniques. Instructions on self-catheterization, assessment of fecal matter, and the prevalence of bowel problems are not specific subjects taught to clients experiencing an alteration in bowel function.

Which risk factors contribute to bowel​ incontinence?

-Long-term diabetes mellitus -Obstetric tears -Neurological disease Individuals with nerve​ damage, including multiple sclerosis and spinal cord​ injury, are at risk of bowel incontinence. Diabetes mellitus contributes to gastroparesis and bowel motility and control problems. Such recommended dietary measures as consuming a​ high-fiber diet and ample fluids to maintain a soft formed stool or maintaining a​ low-residue diet to reduce the number of stools may be beneficial. Kegel exercises to improve sphincter and pelvic floor muscle tone may be of​long-term benefit. Obstetric tears can lead to bowel incontinence.

The nurse is providing home care instructions for a client with fecal incontinence. What information should the nurse​ include?

-Maintain good skin care Rationale: When providing home care teaching with a client experiencing fecal​ incontinence, the nurse needs to educate the client about maintaining good skin care for fecal incontinence because it can cause skin breakdown. The client should use​ bulk-forming laxatives to provide stool bulk and reduce the number of​ small, liquid stools. The client needs to consume a​ high- fiber diet and drink ample fluids to help in maintaining​ soft, well-formed stools.

The nurse is educating the parent's of a preschool-age child about the causes of nocturnal enuresis. Which statements are appropriate for the nurse to include in the teaching session with the parents?

-Many children wet the bed due to difficulties in arousal from sleep -Your child may be constipated. Constipation is a known cause for bed-wetting. -This is caused by an overproduction of urine at night. Rationale: Nocturnal enuresis occurs more often in boys. It can be the result of overproduction of urine at night, difficulties in arousal from sleep, and constipation. There is no indication that nocturnal enuresis is caused by the child being too lazy to get up out of bed at night to urinate.

What are the risk factors for bladder incontinence?

-Medications that affect the adrenergic system -Depression -Obesity -Two or more UTIs per year Rationale: Risk factors for urinary incontinence include two more more UTIs per year, medications that affect the adrenergic systems, depression, and obesity. Clients should eat a high fiber diet to prevent constipation, which is a risk factor for incontinence.

The nurse is speaking to a group of older adults about natural ways to maintain healthy bowel habits. Which bulking agent can be useful in preventing constipation?

-Metamucil -Citrucel -Psyllium seed Learning Objective: Identify collaborative therapies used by interdisciplinary teams. Rationale: Metamucil and Citrucel are bulk-producing laxatives that restore the normal moisture level and bulk content of the intestinal tract. In treating constipation, a bulk-producing laxative retains free water in the intestinal lumen, thereby indirectly opposing the dehydrating forces of the bowel. This action helps the formation of a normal stool. Milk of magnesia (MOM) contains poorly absorbed salts and stimulates peristalsis by irritating the bowel mucosa. MOM is a stimulant, not solely a bulking agent used for the prevention of constipation. Bisacodyl is a laxative that stimulates intestinal motility and secretions. It is not a bulk-forming agent for the prevention of constipation. Psyllium seed is a bulk-producing laxative that promotes peristalsis and natural elimination.

Which health promotion instruction should the nurse give a client regarding​ constipation?

-Monitor bowel intake -Increase fluid intake -Increase exercise Rationale: Exercise increases bowel motility and should be encouraged as a health promotion activity. The nurse should encourage the client to drink plenty of fluids up to 2500 mL per​ day, as​ indicated, to help keep the bowel movements soft. The client should also be taught to monitor bowel habits to see whether certain foods or activities aggravate or alleviate symptoms of constipation. The nurse should encourage the client to consume a​ high-fiber diet to promote bowel motility and help keep the bowel soft. Potassium intake should be monitored with the client with​diarrhea, not constipation.

The nurse is providing care to older clients at a long-term care facility. Many of the nurse's clients experience urinary incontinence. Which factors place these clients at risk for urinary incontinence?

-More than two urinary tract infections (UTIs) in a year -Age -Depression -Stroke Learning objective: Differentiate the pathophysiology, etiology, risk factors, prevention, and clinical manifestations. Rationale: Risk factors for urinary incontinence include age, gender(women are more susceptible than men), obesity, smoking, diabetes, inactivity, pregnancy, depression, neurologic disorders (e.g., stroke), two or more UTIs per year, and medications (medications affecting the adrenergic system, diuretics, and calcium channel blockers,) Kegel exercises decrease the risk of urinary incontinence.

Which factor causes urinary incontinence in older adult clients?

-Neurological conditions -Impaired mobility Rationale: Urinary incontinence may be cause by impaired mobility and neurological conditions. Urine concentration, micturition, and the internal sphincter are not causes of urinary incontinence.

Which data may be noted during the physical examination portion of the nursing assessment for a client diagnosed with incontinence?

-Physical or cognitive limitations -Bladder bulging -Perineal redness Rationale: During the physical examination for a client experiencing urinary incontinence the nurse pay find perineal redness, physical or cognitive limitations, and bladder bulging. The use of alternative therapies is assessed during the client's health history. Bowel sounds are not assessed during a focused urinary assessment.

During a focused physical assessment of the urinary system, a female American Muslim client seems nervous and upset. Which step should the nurse take?

-Present the assessment as a natural process -Discuss other topics to distract the client during the assessment -Have a clinician of the same sex perform the assessment Learning objective: Identify procedures used to determine elimination status across the lifespan. Rationale: Some of the steps the nurses can take while performing this assessment include presenting the assessment as a natural process; discussing other topics to distract the client, and practicing culturally competent care by having a clinician of the same sex perform the assessment. There is no indication that the client does not speak English. Incorporating play into the physical examination is appropriate for a pediatric client, not an adult.

To determine the presence of a fecal impaction, the nurse prepares Janelle for which prescribed procedure?

-Radiographic examination. -Digital rectal examination Rationale: Digital rectal or a radiographic examination is the procedure performed to assess for the presence of a fecal impaction. Rationale: Digital rectal examination is the procedure performed to assess for the presence of a fecal impaction.

After several weeks, the bladder training program is unsuccessful in stopping Mr. Ellis' incontinence. Mr. Ellis appears withdrawn and states that he is frustrated at the number of episodes that he is having. Which nursing diagnoses are appropriate for Mr. Ellis?

-Risk for impaired skin integrity related to urinary incontinence. -Ineffective coping related to inability to control urine leakage. Rationale: The skin of the client with urinary incontinence is frequently exposed to urine, which is irritating to the skin and places the client at risk for impaired skin integrity. The nurse understands that a Braden Scale assessment should be completed on this client and that every effort should be made to prevent the development of pressure ulcers. Rationale: Mr. Ellis' withdrawn behavior and statements of frustration are evidence that he may be having a difficult time dealing with his incontinence.

The nurse notifies the HCP and obtains a prescription for wrist restraints. The nurse applies the restraints and plans to monitor the client every 30 minutes. Which assessments are most important for the nurse to perform at each of these times?

-Skin integrity and pulse volume of the restrained extremities. -Pulse rate and volume in the wrists. Rationale: Wrist restraints can impede circulation, causing tissue damage under the restraint and distal to the restraint. Skin integrity and assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints must be removed at least every 2 hours to allow for range of motion. Rationale: Assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints must be removed at least every 2 hours to allow for range of motion.

The nurse administers the prescribed soap suds enema to illicit irritation to the colon to help with constipation. During the enema, Janelle begins to experience abdominal cramping. What actions should the nurse take to relieve the abdominal cramping?

-Slow the rate of the infusion. -Roll the clamp to stop the enema until cramping subsides. Rationale: Slowing the rate of the enema infusion and reassessing the client ,should reduce or stop the client's abdominal cramping. Rationale: This action will stop or slow down cramping. When cramping decreases, start enema again by slowly releasing the clamp to begin flow.

During an office visit, a client reports infrequent and difficult bowel movements. Which teaching topic is appropriate for this client?

-The importance of staying active -The use of laxatives or stool softeners -The importance of consuming adequate amounts of fluid and fiber Learning objective: Compare common alterations across the lifespan, concepts related to elimination, and prevention. Rationale: Being active and consuming adequate fluids and fiber in the diet can prevent constipation. Clients at high risk of constipation may prevent it by taking daily laxatives or stool softeners. Cooking and storing food properly, and avoiding ray foods during travel would address diarrhea, not constipation.

The nurse is preparing to provide a newly prescribed laxative medication to a client with chronic constipation. What should the nurse discuss with this client before administering the medication?

-Whether the client has recently had abdominal surgery -Whether the client has been experiencing nausea, vomiting, or cramps -Preventive measures for constipation to avoid over dependence on laxatives Learning objective: Explain independent and collaborative interventions for clients with alterations in elimination. Rationale: Laxatives should not be used in clients with nausea, cramps, colic, vomiting, or undiagnosed abdominal pain; or in those who have recently has abdominal surgery. Clients should be taught preventative measures for constipation to avoid over dependence on laxatives because laxatives can weaken the bowel's natural response to fecal distention. The other answer choices address alterations in urination function, not constipation.

After administering the rectal suppository, it is most important for the nurse to document which information?

0900. One bisacodyl suppository administered per rectum for constipation, as prescribed. Rationale: This documentation correctly identifies the medication, the dose, the time, and the route of administration, as well as the reason for administering the medication.

The nursing staff continues with the bladder-training program, but Mr. Ellis' incontinence shows little improvement. Since the bladder training has not been successful, the nurse obtains a prescription to apply a condom catheter. Mr. Ellis is able to ambulate with assistance. In what order should the prescribed condom catheter be applied to Mr. Ellis? (Arrange the options in the order they should be performed with the first action on top and the last action on the bottom.)

1. Clean and dry the penis. 2. Apply skin protecting cream and allow it to dry. 3. Wrap the adhesive spirally around the shaft of the penis. 4. Place the rolled condom over the glans penis and unroll it gently over the penis. 5. Attach a large leg drainage bag to reduce the frequency of bag emptying while the client is ambulatory. Rationale: Before applying a condom catheter, it is important to clean and dry the penis and apply the skin protecting cream that is packaged with the catheter. Next, wrap the adhesive liner spirally around the penis. Place the rolled condom over the glans penis and unroll it gently over the penis and adhesive liner. Make sure that the foreskin remains in place during this process. Finally, attach a drainage bag to collect the urine.

Which statement provides the best documentation describing the outcome from the suppository administration?

1100. Client produced six, ¼ inch, hard pellets of brown stool following suppository administration. Rationale: This documentation provides the most specific objective data related to the effectiveness of the suppository.

The catheter is successfully placed in the bladder with a return of 200 mL of clear, yellow urine. The catheter is secured and Mr. Ellis is resting comfortably. In documenting the catheter insertion procedure, which statement should be included?

16 French Foley catheter inserted with return of clear, yellow urine. Rationale: This statement includes the best objective data, including the size of the catheter and the outcome of the procedure. In addition, the nurse should also document how the client tolerated the procedure and the client's condition following completion of the procedure.

The student nurse instills a total of 60 mL of the correct solution and withdraws 40 mL of fluid containing several small blood clots. The student nurse then empties 200 mL from the urinary drainage bag. What urinary output should be recorded? (Enter the numerical value only. If rounding is required, round to the whole number.)

180 Rationale: 180 The student instilled 20 mL more than was withdrawn, so that amount must be subtracted from the volume emptied from the drainage bag. 200 mL - 20 mL = 180 mL The nurse may instill the irrigant without withdrawing any fluid. In that circumstance, the entire amount of the irrigant must be subtracted from the amount of fluid emptied from the drainage bag to obtain an accurate measurement of the client's urinary output.

How much fluid per day should a client experiencing constipation​ drink?

2500 mL Rationale: A client who is experiencing constipation should drink at least 2500 mL of fluid per day as tolerated.

How will the nurse accurately explain the amount of fluid to Janelle using household measurements?

3 cups Rationale: The conversion factors needed are as follows: 30 mL = 1 ounce, and 1 cup = 8 ounces. 725 mL/30 = 24 ounces/8 = 3 cups.

Mr. Ellis returns from the Post Anesthesia Care Unit (PACU) after his surgical procedure. He has an IV of LR infusing at 125 mL/hr, O2 at 2 L/min per nasal cannula, and an indwelling catheter attached to a drainage bag. Four hours later, the nurse documents Mr. Ellis' intake/output. The LR solution has been running for 4 hours, and the nurse administers and IV antibiotic that runs in 150 mL of normal saline. Mr. Ellis is still NPO after the procedure. How does the nurse document Mr. Ellis' intake in mL? (Enter numerical value only. If rounding is necessary, round to the whole number?)

650 Rationale: 150 mL x 4 = 500 mL of LR 500 mL + 150 mL (antibiotic) = 650 mL

Mr. Ellis' indwelling catheter is removed by the nurse on the morning of Mr. Ellis' anticipated discharge. T he nurse instructs the UAP to report if Mr. Ellis has not voided within how many hours? (Enter numerical value only. If rounding is necessary, round to the whole number.)

8 Rationale: The client should void within 6 to 8 hours after catheter removal. If the client has not urinated by 8 hours post removal, further intervention may be required.

Further assessments and testing are ordered to assist in the diagnosis of constipation. An upper GI series (Barium swallow) is ordered. Janelle appears nervous, and asks the nurse to explain this procedure. Which response by the nurse accurately describes a barium swallow?

A barium liquid is swallowed and a series of x-rays are taken. Rationale: An upper GI series involves swallowing a barium liquid, followed by a series of x-rays taken of the esophagus, stomach and duodenum.

Mr. Ellis' incontinence continues. Use of the condom catheter is resumed until Mr. Ellis develops localized dermatitis. The condom catheter is removed temporarily to promote healing, and although the nursing staff takes Mr. Ellis to the bathroom every 2 hours, he occasionally wets his clothing. The nurse enters Mr. Ellis' room and finds him crying. What is the best initial response by the nurse to this behavior?

Acknowledge to Mr. Ellis the distress that he is experiencing. Rationale: Acknowledgment of a client's distress is a therapeutic and caring response. This should be the first action implemented by the nurse.

Mrs. Goldstein has been admitted for unresolved fecal incontinence. In developing and discussing a bowel training program for Mrs.​ Goldstein, which action is not​ appropriate?

Administer a bulk laxative per order Rationale: A bulk laxative is appropriate only for a client who is experiencing​ constipation, not fecal incontinence. Having Mrs. Goldstein use the bathroom in her normal bowel routine will help promote defecation. To stimulate​ peristalsis, administer a cathartic suppository​ (e.g., glycerin or​ bisacodyl) 30 minutes before the​ client's usual defecation time. When the client experiences the urge to​ defecate, assist the client to the toilet or commode or onto a​ bedpan, and note the length of time between the administration of the suppository and defecation. Provide the client privacy for​defecation; and teach the client to lean forward at the hips and apply pressure to the abdomen with her hands to increase pressure on the colon and avoid straining.

The nurse notifies the HCP of the presence of a fecal impaction and receives a verbal prescription over the telephone for enema administration. What action should the nurse implement?

Administer the enema as prescribed and obtain the HCP's signature the next day. Rationale: A verbal prescription is legally permissible. The nurse should, however, take measures to ensure client safety because verbal prescriptions can be a source of error. The nurse should read back the complete prescription and have the verbal prescription signed within 24 hours. Some healthcare agencies do not allow verbal prescriptions, so it is important for the nurse to adhere to agency policy.

A client is experiencing increased urinary urgency and incontinence. Which medication does the nurse anticipate will be prescribed for this client?

Anicholinergic agent Learning objective: Explain independent and collaborative interventions for clients with alterations in elimination. Rationale: Anticholinergics are . used to relieve symptoms associated with voiding in clients who have urge incontinence. Cholinergic agents, diuretics, and antiflatulents are not appropriate for this client.

The nurse is caring for a group of residents in a​ long-term care facility. Which​ condition, if present in a​ resident, would be the most likely cause of fecal​ incontinence?

Anorectal injury Rationale: Irritable bowel syndrome may cause diarrhea but not necessarily incontinence. If the external anal sphincter is paralyzed by injury or disease​ (anorectal injury), defecation occurs automatically when the internal sphincter relaxes. Parkinson disease is a neurologic disorder caused by a lack of the neurotransmitter dopamine. It results in​ tremor, not fecal incontinence. Gastrointestinal reflux disease is the regurgitation of stomach acids back into the esophagus. It does not cause fecal incontinence.

The UAP obtains sterile gloves and lubricant for the nurse and offers to perform the procedure since the nurse is busy. Which action is the most important for the nurse to implement?

Ask the UAP to assist with client positioning while the nurse performs the procedure, while teaching the UAP about the correct supplies needed. Rationale: This task should not be delegated to the UAP because it is an invasive procedure that places a client at risk. The UAP can be assigned to assist the nurse with client positioning. Having the UAP assist in this manner provides an opportunity for the nurse to teach the UAP that this is not a sterile procedure. The nurse should use nonsterile exam gloves, which are less costly than sterile gloves, and lubricant for this procedure.

Maudie May is an 82-year-old female who is residing in a long-term care facility. Until recently, her family had cared for her at home. Maudie's senile dementia, along with an increasing toileting deficit, had made it difficult for her family to continue to care for her at home. Which nursing action is appropriate when providing care for Ms. May?

Assess Ms. May for physical and mental abilities and limitations, usual voiding pattern, and ability to assist with toileting. Rationale: Assessing the client for physical and mental abilities, usually voiding pattern, and ability to assist with toileting will assist in planning her care. Holding medications that cause diuresis may cause the client to develop additional health problems with the renal or cardiovascular systems. Performing intermittent catheterization on a routine basis increases the chance for infection. Reducing fluid intake to less than 1.5 liters can cause irritation of the bladder due to urine concentration and increase incontinence.

The nurse observes that Janelle's abdomen is firm and distended. The nurse performs an abdominal assessment. Which assessment is most important for the nurse to perform?

Auscultate bowel sounds Rationale: The subjective data reported by Janelle (bloated and nauseated) and objective data gathered by the nurse (abdomen firm and distended) suggest that Janelle may have decreased peristalsis. This can be assessed by auscultation of the bowel sounds.

At a recent checkup with his primary care physician, Tom Anderson complained of feeling as if his Bladder was always full. This made frequent trips to the bathroom necessary. Mr. Anderson said he had difficulty starting his urine stream and he had a weak urine flow. After a post-voiding catheterization obtained 250 mL of urine, Mr. Anderson was diagnosed with chronic urinary retention. Which clinical therapy do you anticipate for the client?

Bethanechol chloride (Urecholine) Rationale: Bethanechol chloride (Urecholine) is a cholinergic medication used to promote contraction of the detrusor muscle and emptying of the bladder. Imipramine (Tofranil) and urethral inserts are used for stress incontinence. Neuromodulation is a clinical therapy for reflex incontinence.

A male client is experiencing bowel issues that alternate between episodes of constipation and episodes of diarrhea. Which diagnostic test does the nurse anticipate will be ordered for this client?

Blood test Rationale: Blood tests are used for the identification of systemic causes of alterations in bowel function. A cystoscopy, urinalysis, and renal ultrasound would be anticipated for a client who is experiencing alterations in urinary function.

When the subject of diet comes​ up, Mr. and Mrs. Avila talk about how they love to garden. Restricting raw​ vegetables, especially their heirloom​ tomatoes, will mean some changes in their daily food routines. "But we'll get through it ​together," Mr. Avila assures you. He then asks you when they need to notify the health care provider.​ What event do you tell him would warrant immediate contact with a health care​ provider?

Blue or purple stoma Rationale: If Mr. or Mrs. Avila see the stoma turn blue or​ purple, that indicates impaired blood circulation. Mrs. Avila​'s health care provider should be notified immediately.​ Otherwise, diarrhea, very smelly​ feces, or lots of gas in the pouch are no reason to contact her health care​ provider; they are expected situations.

The nurse is caring for a client in a long-term care facility who has nit had a bowel movement in 5 days. The unlicensed assistive personnel report that the client is passing a very small amount of liquid stool. What action should the nurse take initially.

Check the client for impaction Learning objective: Apply the nursing process to provide culturally competent care across the lifespan. Rationale: The nurse needs to check the client for an impaction because the liquid stool is likely to seep around the impaction. The smearing of liquid stool is a common symptom of an impaction. The question asks what the nurse should do initially.Although the nurse ay report her findings to the health care provider, this should not be the initial action. The nurse must first ascertain whether the client is impacted. An impaction must be removed digitally. A laxative may be appropriate in the future but not initially. The nurse needs to record her findings, but only after adequately assessing the client for impaction.

The father of a 3-year-old boy is concerned that his son still wets the bed at night. Which explanation by the nurse is most appropriate regarding bedwetting?

Children often achieve daytime bladder control prior to nighttime bladder control. Rationale: Bladder control is attained by ages 2-5 years, often with daytime control attained prior to nighttime control. The other statements by the nurse do not address the father's concern.

The nurse is providing care to a client diagnosed with urinary retention. The healthcare provider prescribes pharmacologic therapy for the client. Which type of medication will the nurse include in the discharge teaching for this client?

Cholinergic medications Learning objective: Identify collaborative therapies used by interdisciplinary teams. Rationale: Cholinergic medications promote contraction of the detrusor muscle and emptying of the bladder. Imipramine (Tofranil) contracts the smooth muscles of the bladder neck to treat incontinence. Oxybutynin (Ditropan, Ditropan XL) is used to treat urge incontinence and increase bladder capacity. Estrogen therapy is used to treat incontinence casued by postmenopausal atrophic vaginitis.

Mr. Ellis is responsive but confused and frequently pulls on the urinary catheter. The nurse observes obvious hematuria in the drainage bag and notes the presence of several blood clots in the tubing. How should the nurse document this situation?

Client is confused and pulls on the Foley catheter. Urine is pinkish-red with blood clots. Rationale: This recording is concise but complete, providing objective data that describes the current situation.

Which treatment is useful in the therapeutic management of ​constipation?

Complementary therapy Complementary therapy such as​ acupressure, massage,​ reflexology, biofeedback, aromatherapy and stress management are helpful in the management of constipation and fecal impaction. Dietary changes include incorporating such​ high-fiber foods as fruits and vegetables and​ whole-grain breads into the diet.

The nurse administers the first dose of docusate sodium. This medication primarily alters which aspect of a client's bowel movement?

Consistency Rationale: Docusate sodium is a stool softener. The desired effect is to soften hard stool (alter the consistency) for ease of elimination.

The nurse determines that Janelle's inadequate fluid intake, decreased mobility, and opiod use are significant factors in the development of her constipation. Which nursing diagnosis should the nurse include in Janelle's plan of care?

Constipation related to surgery and anesthesia. Rationale: This diagnostic statement uses the correct format and identifies both the problem and the etiology.

While performing the digital rectal exam, the nurse recognizes that the client may experience vagal nerve stimulation. This can result in which change in vital signs?

Decreased pulse rate Rationale: Vagal nerve stimulation can cause a reflex slowing of the heart rate.

The student obtains a 16 French Foley catheter from the supply room. The student nurse explains the procedure to Mr. Ellis, who gives permission to begin. After cleansing the urinary meatus, the student nurse maintains sterile technique while inserting the catheter into the urethra about 4 inches. While inflating the balloon, Mr. Ellis cries out in obvious pain. What action should the student nurse take?

Deflate the balloon and insert the catheter farther. Rationale: The catheter has not been inserted far enough, and the pressure of the inflated balloon in the urethra is painful. Since the student nurse has maintained aseptic technique, the balloon can be deflated and the catheter inserted farther. Typically, the catheter should be inserted 6 to 9 inches to ensure proper placement in the adult male.

Mr.​ Phillips, age​ 55, has been admitted with abdominal​ pain, history of chronic​ constipation, and possible fecal impaction. Which diagnostic test might the nurse anticipate will influence the type of treatment to be​ implemented?

Digital rectal exam Rationale: The nurse should anticipate that a digital rectal exam will be done to determine whether the client is impacted. An upper​ endoscopy, abdominal​ ultrasound, or chest​ x-ray will not assist in determining whether the client is experiencing fecal impaction.

The nurse is caring for Adele Simpson, a 60-year-old female being treated for constipation. Which procedure should the nurse teach Adele to help establish regular bowel movements?

Digital stimulation Rationale: Bowel training/digital stimulation can be used or taught to the client to establish regular defecation. Kegel exercises are useful in the treatment of urinary incontinence. Anal hygiene will not help to establish regular defecation. Self-catheterization is appropriate for a client with urinary retention.

The nurse is providing care to a client diagnosed with urinary retention. Which medication on the client's medical administration record would the nurse question for this client?

Diphenhydramine hydrochloride Rationale: The nurse would question the use of an antihistamine, such as diphenhydramine hydrochloride, for a client with urinary retention. Bethanechol chloride is a medication used to treat urinary retention. Acetaminophen and ibuprofen can be administered safely for a client with urinary retention.

Mrs.​ Jones, age​ 75, has just been diagnosed with a fecal impaction. She tells the nurse that she has never heard of this condition before and wonders whether it is fatal. What is the​ nurse's best​ response?

​"This is a condition in which hard stool collects in the rectal area and colon for an extended period of​ time." Rationale: The nurse has knowledge of the disease process and is responsible for providing information to the client when asked. Constipation and fecal impaction affects older adults more frequently than younger adults. Telling the client it is nothing to worry about is not therapeutic. In​ addition, impaction is not a really painful process. Acknowledging worry is therapeutic but​ doesn't address the​ client's question. Fecal impaction is a collection of hardened stool in the rectal area and the colon over an extended period of time. Fecal incontinence is the loss of voluntary control of defecation.

You ask Mrs. Avila if you can check her ostomy​ set-up and she agrees. You wash your​ hands, glove, and draw the curtain around her bed. You find that her drainable pouch is more than​ two-thirds full. What teaching point will you​ make?

​"When your pouch is​ one-third to​ one-half full,​ it's time to empty your​ pouch." Rationale: You are teaching Mrs. Avila that an ostomy pouch should be emptied when it is​ one-third to​ one-half full. It is essential to prevent the ostomy pouch from filling​ completely, as an overfilled pouch can cause separation of the skin barrier from the skin. This allows stool to come in contact with the​ skin, which could cause skin breakdown. Scolding Mrs. Avila is neither therapeutic nor appropriate.