Practice Question
A reclining position on the left side (Sims' position) is recommended. The head may be slightly elevated, but Fowler's position should be avoided because the solution will remain in the rectum and expulsion will occur rapidly, resulting in minimal cleansing. Which is an expected outcome for a client undergoing a bowel training program? A) Have a soft, formed stool at regular intervals without a laxative. B) Continue to use laxatives, but use one less irritating to the rectum. C) Use oil-retention enemas on a regular basis for elimination. D) Have a formed stool at least twice a day for two weeks.
A
A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra. A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate? A) Increased output of dilute urine B) Increased urine concentration C) A risk of urinary tract infections D) Transient incontinence and increased urine production
A
About 800 to 1,000 mL of liquid is absorbed daily by the large intestine. When absorption does not occur properly, such as when the waste products pass through the large intestine rapidly, the stool is soft and watery. A nurse is assessing the stools of a breastfed baby. What is the appearance of normal stools for this baby? A) Yellow, loose, odorless B) Brown, paste-like, some odor C) Brown, formed, strong odor D) Black, semiformed, no odor
A
Acombination of high-fiber foods, 8 to 10 glasses of water a day, and exercise has been shown to be as effective as medications in controlling constipation. Caution the client to avoid increasing fiber intake without drinking enough fluids because this can lead to a bowel obstruction. A nurse is documenting the appearance of feces from a client with a permanent ileostomy. Which of the following would she document? A) "Ileostomy bag half filled with liquid feces." B) "Ileostomy bag half filled with hard, formed feces." C) "Colostomy bag intact without feces." D) "Colostomy bag filled with flatus and feces."
A
Damage to the subcutaneous tissue indicates a stage III ulcer. Extensive destruction associated with full-thickness skin loss is categorized as a stage IV pressure ulcer. A stage I ulcer is a defined area of persistent redness in lightly pigmented skin and a persistent red, blue, or purple hue in darker pigmented skin. A stage II pressure ulcer is superficial and may present as a blister or abrasion. When measuring the size, depth, and wound tunneling of a client's stage IV pressure ulcer, what action should the nurse perform first? A) Perform hand hygiene. B) Insert a swab into the wound at 90 degrees. C) Measure the width of the wound with a disposable ruler. D) Assess the condition of the visible wound bed.
A
Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. The diminished ability of the kidneys to concentrate urine may result in nocturia (urination during the night). Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control and the ability to reach a toilet in time. Individuals who view themselves as old, powerless, and neglected may cease to value voluntary control over urination, and simply find toileting too much bother no matter what the setting. Incontinence may be the result. A nurse is assessing the urine output of a client with Parkinson's disease who is on levodopa. Which of the following is a common finding for a client on this medication? A) The urine may be brown or black. B) The urine may be blood-tinged. C) The urine may be green or blue-green. D) The urine may be orange or orange-red.
A
During a visit to the pediatrician's office, a parent inquires about toilet training her daughter age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when ... A) the child can recognize bladder fullness. B) the child can hold the urine for four to five hours. C) The child cannot control urination until seated on the toilet. D) The child ignores the desire to void.
A
During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma. A nurse is following a physician's order to irrigate the NG tube of a client. Which of the following is a recommended guideline in this procedure? A) Assist client to 30- to 45-degree position, unless this is contraindicated. B) Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe. C) If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent. D) If unable to irrigate the tube, reposition client and attempt irrigation again; inject 20 to 30 mL of air and aspirate again.
A
During the first six to eight weeks after surgery, the nurse should encourage the client with an ostomy to avoid foods high in fiber (e.g., foods with skins, seeds, and shells) as well as any other foods that cause diarrhea or excessive flatus. By gradually adding new foods, the ostomy client can progress to a normal diet. The nurse should urge clients to drink at least two quarts of fluids, preferably water, daily. The use of liquid, chewable, or injectable forms rather than long- acting, enteric-coated, or sustained-release medications is recommended. Laxatives and enemas are dangerous because they may cause severe fluid and electrolyte imbalance. A nurse is assessing a client with constipation and severe rectal pain. Which of the following actions should the nurse perform to determine the presence of fecal impaction? A) Inserted a lubricated, gloved finger into the rectum. B) Obtain a sharp intestinal x-ray. C) Insert a lubricated rectal tube into the rectum. D) Administer an oil retention enema into the rectum.
A
Hand hygiene should precede any wound assessment or wound treatment. The nurse would recognize which of these devices as an open drainage system? A) Penrose drain B) Jackson-Pratt drain C) Hemovac D) Negative pressure dressing
A
Infants are born with little ability to concentrate urine. An infant's urine is usually very light in color and without odor until about 6 weeks of age, when the nephrons are able to control reabsorption of fluids and effectively concentrate urine. Infants do not normally have scanty, highly concentrated, or dark and odorous urine. An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging? A) Diminished kidney ability to concentrate urine B) Increased bladder muscle tone causing urinary frequency C) Increased bladder contractility causing urinary stasis D) Decreased intake of fluids during daytime hours
A
Levodopa (l-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine. Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine (Pyridium), a urinary tract analgesic, can cause orange or orange-red urine. A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? A) Urinary incontinence B) Urinary incompetence C) Normal micturition D) Uncontrolled voiding
A
Many people have difficulty digesting lactose (the sugar contained in milk products). The breakdown of lactose into its component sugars, glucose and galactose, requires a sufficient quantity of the enzyme lactase in the small intestine. If a person is lactose-deficient, alterations of bowel elimination, including formation of gas, abdominal cramping, and diarrhea, can occur after ingestion of milk products. A nurse assesses the abdomen of a client before and after administering a small-volume cleansing enema. What condition would be an expected finding? A) Increased bowel sounds B) Abdominal tenderness C) Areas of distention D) Muscular resistance
A
Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on gross examination. It can be detected with simple screening tests, such as a Hematest. A nurse is scheduling diagnostic studies for client. Which test would be performed first? A) Fecal occult blood test B) Barium study C) Endoscopic exam D) Upper gastrointestinal series
A
Peristalsis is defined as the contractions of the circular and longitudinal muscles of the intestine. Decreased peristalsis will result in constipation because the movement of the fecal mass will occur at a slower rate and more fluid will be absorbed in the colon. During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following? A) An increase in the client's blood pressure B) A decrease in the client's blood pressure C) An increase in the client's respiratory rate D) A decrease in the client's respiratory rate
A
Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the diminished ability to concentrate urine that may result in nocturia (voiding during the night). Aging does not result in increased bladder muscle tone or increased bladder contractility. A decrease in fluid intake would not result in nocturia. After surgery, a postoperative client has not voided for eight hours. Where would the nurse assess the bladder for distention? A) Between the symphysis pubis and the umbilicus B) Over the costovertebral region of the flank C) In the left lower quadrant of the abdomen D) Between ribs 11 and 12 and the umbilicus
A
Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition. A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which of the following positions would the nurse place the client? A) Supine B) Sims' C) High Fowler's D) Dorsal recumbent
A
The anatomy of the urethra differs in males and females. The male urethra is about 51/2 to 61/4 inches (13.7 to 16.2 cm) long. The female urethra is about 11/2 to 21/2 inches (3.7 to 6.2 cm) long. This difference is important in terms of catheterization and risk for infection. Which of the following describes the term micturition? A) Emptying the bladder B) Catheterizing the bladder C) Collecting a urine specimen D) Experiencing total incontinence
A
The collection is initiated at a specific time, but the client is asked to void at that time and discard the urine from the first voiding. In most instances, a preservative is added to the collection bottle, or the collected urine is kept cold through refrigeration or putting it on ice. An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses? A) Social Isolation B) Impaired Adjustment C) Defensive Coping D) Impaired Memory
A
The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool, not assess it. The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation of the abdomen for which reason? A) Detect abdominal masses B) Determine abdominal firmness C) Assess softness of abdominal muscles D) Assess degree of abdominal distention
A
The nursing instructor informs a student nurse that a client she is caring for has a chronic neurologic condition that decreases the client's peristalsis. What nursing diagnosis is the most likely risk for this client? A) Constipation B) Diarrhea C) Deficient fluid volume D) Excessive fluid volume
A
The proliferation phase is characterized by the formation of granulation tissue (highly vascular, red tissue that bleeds easily). During the proliferation phase, new tissue is built to fill the wound space. Hemostasis involves the constriction of blood vessels and the beginning of blood clotting immediately after the initial injury. The inflammatory phase lasts about four to six days, and white blood cells and macrophages move to the wound. The maturation phase is the final phase of wound healing and involves remodeling of collagen that was haphazardly deposited in the wound; in addition,a scar forms. Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the physician and doing which of the following? A) Covering the wound area with sterile towels moistened with sterile 0.9% saline B) Closing the wound area with Steri-Strips C) Pouring sterile hydrogen peroxide into the abdominal cavity and packing with gauze D) Holding the wound together until the physician arrives
A
The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Inspection and auscultation are performed before palpation because palpation may disturb normal peristalsis and bowel motility. What are two essential techniques when collecting a stool specimen? A) Hand hygiene and wearing gloves B) Following policies and selecting containers C) Wearing goggles and an isolation gown D) Using a no-touch method and toilet paper
A
The skin provides multiple functions: protection, temperature regulation, psychosocial, sensation, vitamin D production, immunological, absorption, and elimination. While performing a bed bath, the nurse notes an area of tissue injury on the client's sacral area. The wound presents as a shallow open ulcer with a red-pink wound bed and partial thickness loss of dermis. Which of the following is the correct name of this wound? A) Stage II pressure ulcer B) Stage I pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer
A
To protect clients at risk from the adverse effects of pressure, implement turning using an every-2-hour schedule in the health care setting. More frequent position changes may be necessary. Never use ring cushions or "donuts." A nurse is assessing a client with a stage IV pressure ulcer. What assessment of the ulcer would be expected? A) Full-thickness skin loss B) Skin pallor C) Blister formation D) Eschar formation
A
Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet. A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A) Suprapubic catheter B) Indwelling urethral catheter C) Intermittent urethral catheter D) Straight catheter
A
Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue easily bleeds when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment? A) Proliferation phase B) Hemostasis C) Inflammatory phase D) Maturation phase
A
Urinary incontinence is a special problem for older adults who may have decreasing control over micturition, or find it more difficult to reach the toilet in time. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person's self-concept, causing him or her to feel like a social outcast. A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding? A) Assist him to a standing position. B) Tell him he has to void to be discharged. C) Pour cold water over his genitalia. D) Ask his wife to assist with the urinal.
A
When an individual bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart; this act elevates the client's blood pressure. While caring for an infant who is breast-fed, the nurse assesses the characteristics of the stools. What stool characteristics are expected in breast-fed infants? A) Golden yellow and loose B) Dark brown and firm C) Y ellow-brown and pasty D) Green and mucusy
A
When infants and children become ill, they lose most fluids from their extracellular compartment, which quickly leads to dehydration. The nurse would assess skin turgor to identify this problem. A client tells the nurse that he takes laxatives every day but is still constipated. The nurse's response is based on: A) Habitual laxative use is the most common cause of chronic constipation. B) If laxatives are not effective, the client should begin to use enemas. C) A laxative that works by a different method should be used. D) Chronic constipation is nothing to be concerned about.
A
When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should always be obtained from the catheter itself using the special collection port. A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection? A) V oid and discard the urine. B) Begin the collection at a specific time. C) Add the first voiding to the specimen. D) Keep the urine warm during collection.
A
Deep tissue injury may be difficult to detect in individuals with dark skin tones. The area may be preceded by tissue that is painful, firm, boggy, warmer or cooler as compared with adjacent tissue. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages? A) Stage I B) Stage II C) Stage III D) Stage IV
C
Diuretics result in moderate to severe increases in the production of dilute urine. Concentration will decrease, not increase, and there is no accompanying risk of urinary tract infections. For some clients, this sudden increase in urine output may precipitate transient incontinence, but this remains an abnormal finding. A nurse is preparing to catheterize a female client. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra? A) Has different innervation B) No connection with bladder C) Shorter in length D) Longer in length
C
Gloves are required when handling urine to prevent exposure to pathogenic microorganisms or blood that may be present in the urine. In addition, goggles are also worn if there is a concern of urine splashing. A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching? A) "I need to tell you that I am having my menstrual period." B) "I will void into the specimen bottle you gave me." C) "I will keep the toilet paper in the specimen." D) "I will be sure that no stool is included in my urine."
C
Helping clients assume their usual voiding positions may be all that is necessary to resolve an inability to void. If male clients cannot void lying down, encourage them to void while standing at the bedside unless this is contraindicated. A nurse is educating a client on the amount of water to drink each day. What is the recommended daily fluid intake for adults? A) 1 to 2 (4-oz) glasses per day B) 5 to 6 (6-oz) glasses per day C) 8 to 10 (8-oz) glasses per day D) 16 to 20 (12-oz) glasses per day
C
If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% saline. The client should also be placed in the low Fowler's position, and the exposed abdominal contents should be covered as previously discussed. Notify the physician immediately because this is a medical emergency. Do not leave the client alone. The wound care clinical nurse specialist has been consulted to evaluate a wound on the leg of a client with diabetes. The wound care nurse determines that damage has occurred to the subcutaneous tissues; how would she document this 3. wound? A) Stage I pressure ulcer B) Stage II pressure ulcer C) Stage III pressure ulcer D) Stage IV pressure ulcer
C
Of the many topics that may be taught to clients or caregivers about home wound care, which one is the most significant in preventing wound infections? A) Taking medications as prescribed B) Proper intake of food and fluids C) Thorough hand hygiene D) Adequate sleep and rest
C
Stage I is defined as intact skin with a localized area of nonblanchable redness, usually over a bony prominence. Stage II is defined as partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed. Stage III is defined as full-thickness loss without exposed bone, tendon, or muscle. Stage IV is defined as full-thickness tissue loss with exposed bone, tendon, and muscle. A nurse is treating the pressure ulcer of an African American client. How would the nurse assess for deep tissue injury in this client? A) Upon inspection the nurse would notice a purple or maroon localized area of discolored, intact skin. Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or B) shear. Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, warmer or C) cooler as compared with adjacent tissue. Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink D) wound bed, without slough.
C
Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include drying the perineal area after urination or defecation from the front to the back (or from urethra to rectum). A client is taking diuretics. What should the nurse teach the client about his urine? A) Urinary output will be decreased. B) Urinary output will be increased. C) Urine will be a pale yellow color. D) Urine may be brown or black.
C
The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds. A physician orders a retention enema for a client to destroy intestinal parasites. Which of the following enemas would be indicated for this client? A) Oil retention enema B) Carminative enema C) Anthelmintic enema D) Nutritive enema
C
The nurse could document the client's condition as dysuria, which is difficulty or discomfort when voiding. Dysuria is a common symptom of trauma to the urethra or bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24 hours. Oliguria indicates inadequate elimination of urine. Polyuria is the term used to indicate greater than normal urinary volume, and may accompany minor dietary variations. A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? A) Condom catheter B) Urinary bag C) Straight catheter D) Retention catheter
C
The nurse should document the drainage as serosanguineous, which is pale pink-yellow, thin, and contains plasma and red cells. Serous drainage is pale yellow and watery, like the fluid from a blister. Sanguineous drainage is bloody, as from an acute laceration. Purulent drainage contains white cells and microorganisms and occurs when infection is present. It is thick and opaque and can vary from pale yellow to green or tan, depending on the offending organism. An older adult client has edema of the right lower extremity with redness and clear drainage. This is most likely related to what? A) Beta-hemolytic streptococcus B) Age C) V enous insufficiency D) Hemangioma
C
The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purple- blue color (possible ischemia), or bleeding. A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse assesses no feces in the collection bag. What should the nurse do next? A) Notify the physician immediately. B) Ask another nurse to check her findings. C) Nothing; this is normal. D) Recheck the bag in two hours.
C
The process of emptying the bladder is known as urination, micturition, or voiding. A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. Which is a recommended guideline for initiating this training? A) The child should be able to hold urine for four hours. B) The child should be between 18 and 24 months old. C) The child should be able to communicate the need to void. D) The child does not need the desire to gain control of voiding.
C
The purpose of the deep palpation is to detect abdominal masses. Light palpation of the abdomen helps to determine the firmness or softness of the abdominal muscles and the degree of abdominal distention. A nurse is providing care to a client who has undergone a colonoscopy. Which of the following would be most appropriate for the nurse to do after the procedure? A) Avoid giving solid food B) Administer a laxative to the client C) Monitor for rectal bleeding D) Limit oral fluid intake
C
To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into syringe. If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again. Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the correct order. 1. Cleanse entire perianal area and pat dry.2. Apply skin protectant and allow it to dry. 3. Separate buttocks and apply the pouch to the anal area. 4. Attach the pouch to a urinary drainage bag. 5. Hang the drainage bag below the patient. A) 2, 3, 4, 5, 1 B) 3, 4, 5, 1, 2 C) 1, 2, 3, 4, 5 D) 5, 4, 3, 2, 1
C
Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Incontinence is involuntary loss of urine from the bladder. Retention is an accumulation of urine in the bladder. Frequency is voiding more often than usual. A nurse is assessing the urine on a newborn's diaper. What would be a normal assessment finding? A) Scanty to no urine B) Highly concentrated urine C) Light in color and odorless D) Dark in color and odorous
C
Voluntary control of the urethral sphincters occurs between 18 and 24 months of age. However, many other factors are required to achieve conscious control of bladder function, and toilet training usually begins at about 2 to 3 years of age. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet. The child's desire to gain control is also important. A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. B) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract C) infection. D) Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence.
C
A closed wound results from a blow, force, or strain caused by trauma (such as a fall, an assault, or a motor vehicle crash). The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas. An open wound occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions. What are the two major processes involved in the inflammatory phase of wound healing? A) Bleeding is stimulated, epithelial cells are deposited B) Granulation tissue is formed, collagen is deposited C) Collagen is remodeled, avascular scar forms D) Blood clotting is initiated, WBCs move into the wound
D
A stage IV pressure ulcer is characterized by the extensive destruction associated with full-thickness skin loss. During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? A) Document the assessments and intervention. B) Reinforce the dressing with additional layers. C) Administer pain medications intramuscularly. D) Notify the physician and prepare for surgery.
D
A student has been assigned to provide morning care to a client. The plan of care includes the information that the client requires partial care. What will the student do? A) Provide total physical hygiene, including perineal care. B) Provide total physical hygiene, excluding hair care. C) Provide supplies and orient to the bathroom. D) Provide supplies and assist with hard-to-reach areas.
D
Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (8 to 10 8-oz glasses) of fluid daily. Monitor fluid intake for those that are high in caffeine, sodium, and sugar. A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill? A) Deflate the balloon by aspirating the fluid. B) Ask the client to take several deep breaths. C) Tell the client burning may initially occur. D) Wash hands and put on gloves.
D
Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The nurse should inform the client about this side effect of the medication. A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client's anxiety? A) "We do these procedures every day, so you don't need to worry." B) "I have had this done to me, and it only hurt for a little while." C) "Why are you so worried? Do you think you have a tumor?" D) "Let me explain to you what they do during this procedure."
D
Clients frequently turn to absorbent products for protection when they are incontinent of urine and if they have not had this condition properly diagnosed and treated. When used improperly, such products may cause skin breakdown and place the client at risk for a UTI. A school nurse is educating a class of middle-school girls on how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information? A) "I will take showers rather than baths." B) "I will wear underpants with cotton crotches." C) "I will tell my parents if I have burning or pain." D) "I will wipe back to front after going to the toilet."
D
Clients who are taking corticosteroid medications are at high risk for delayed healing and wound complications such as infections, because corticosteroids decrease the inflammatory process that may in turn delay healing. A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? A) A client 83 years of age who is mobile B) A client 92 years of age who uses a walker C) A client 75 years of age who uses a cane D) A client 86 years of age who is bedfast
D
For digital removal of stool: Position the client on the left side (Sims' position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal. A nurse assessing a client with an ostomy appliance documents the condition "prolapse" in the client chart and notifies the physician. Which of the following statements describes this condition? A) The peristomal skin is excoriated or irritated because the appliance is cut too large. B) The system has leaks or poor adhesion leading to noticeable odor. C) The bag continues to come loose and become inverted. D) The stoma is protruding into the bag and may become twisted.
D
In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. In stage I there is intact skin with nonblanchable redness of a localized area, usually over a bony prominence. In stage II there is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. In stage IV, there is full-thickness tissue loss with exposed bone, tendon, or muscle.Which of the following is an accurate step when applying a saline-moistened dressing on a client's wound? A) Do not use irrigation to clean the wound before changing the dressing. B) Hold the fine-mesh gauze over the basin and pour the ordered solution over the mesh to saturate it. C) Exert light pressure to pack the wound tightly with moistened dressing. D) Apply several dry, sterile gauze pads over the wet gauze and place the ABD pad over the gauze.
D
Most people assume the squatting or slightly forward-sitting position with the thighs flexed to defecate. These positions result in increased pressure on the abdomen and downward pressure on the rectum to facilitate defecation. Obtaining the same results when seated on a bedpan is difficult. The following foods are a part of a client's daily diet: high-fiber cereals, fruits, vegetables, 2,500 mL of fluids. What would the nurse tell the client to change? A) Decrease high-fiber foods B) Decrease amount of fluids C) Omit fruits if eating vegetables D) Nothing; this is a good diet
D
Occasional use of laxatives is not harmful for most people, but they should not become dependent on them. Although many people do take laxatives because they believe they are constipated, most are unaware that habitual use of laxatives is the most common cause of chronic constipation. A client who has been on a medication that caused diarrhea is now off the medication. What could the nurse suggest to promote the return of normal flora? A) Stool-softening laxatives, such as Colace B) Increasing fluid intake to 3,000 mL/day C) Drinking fluids with a high sugar content D) Eating fermented products, such as yogurt
D
Outbreaks of food poisoning can result in severe gastrointestinal symptoms. Severe abdominal cramping followed by watery or bloody diarrhea may signal a microbial infection, which can be confirmed by a stool sample. A nurse is conducting an abdominal assessment. What is the rationale for palpating the abdomen last in the sequence when conducting an abdominal assessment? A) It is the most painful assessment method B) It is the most embarrassing assessment method C) To allow time for the examiner's hands to warm D) It disturbs normal peristalsis and bowel motility
D
Protrusion of the intestines through an opened wound indicates evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required. A nurse assessing a client's wound documents the finding of purulent drainage. What is the composition of this type of drainage? A) Clear, watery blood B) Large numbers of red blood cells C) Mixture of serum and red blood cells D) White blood cells, debris, bacteria
D
The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The equipment used for catheterization is usually prepackaged in a sterile disposable kit or tray. A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information? A) "I understand these will help me control stress incontinence." B) "I know this is also called pelvic floor muscle training." C) "I will do these 30 to 80 times a day for two months." D) "I will contract the muscles in my abdomen and thighs."
D
The client with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid. A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma? A) Pallor B) Purple-blue C) Irritation and bleeding D) Dark red and moist
D
The plan of care for a postoperative client specifies that sterile 0.9% sodium chloride solution be used to clean the wound. What should the nurse do after reading this information? A) Question the physician about the accuracy of this agent. B) Refuse to use 0.9% normal saline on a wound. C) Document the rationale for not changing the dressing. D) Continue with the dressing change as planned.
D
The proliferative phase of wound healing begins within two to three days of the injury. Collagen synthesis and accumulation continue, peaking in five to seven days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations. A home health nurse has a caseload of several postoperative clients. Which one would be most likely to require a longer period of care? A) An infant B) A young adult C) A middle adult D) An older adult
D
The sight of the wound may disturb a client. If the wound involves a change in normal body functions or appearance, the pclient may not want to look at the wound. With patience and emotional support, clients learn to cope with and adapt to their wounds in time. A nurse is teaching a client on home care about how to apply hot packs to an infected leg ulcer. What statement by the client indicates the need for further education? A) "I understand the rebound effect of heat." B) "I will put the heat packs only on the sore on my leg." C) "I will only leave the heat packs on for 20 minutes." D) "I will leave the heat packs on for an hour."
D
The single most important information on which to educate clients and caregivers about home wound care is the importance of thorough hand hygiene to prevent wound infections. Which of the following is a recommended guideline nurses follow when using an electric heating pad on a client? A) Secure the heating pad to the client's clothing with safety pins. B) Place a heavy towel or blanket over the heating pad to maximize heat effects. C) Use a heating pad with a selector switch that can be turned up by the client if needed. D) Place a heating pad anteriorly or laterally to, not under, the body part.
D
Urine for a routine urinalysis does not have to be sterile. Ask the client to void into a clean receptacle and avoid contamination with stool. Note on the request form if a woman is having her menstrual period. Instruct clients not to put toilet paper into the urine because this makes analysis more difficult. A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen? A) Pour urine from the collecting bag. B) Remove the catheter and ask the client to void. C) Aspirate urine from the collecting bag. D) Aspirate urine from the collection port.
D
Use of medical aseptic techniques when collecting a stool specimen is imperative. Hand hygiene, before and after wearing rubber gloves, is essential. What is occult blood? A) Bright red visible blood B) Dark black visible blood C) Blood that contains mucus D) Blood that cannot be seen
D
Various diagnostic procedures, typically performed in a hospital operating room or outpatient facility, are used to study the urinary system. Nurses are responsible for preparing the client and giving aftercare. Explaining the procedure helps reduce the client's anxiety. A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? A) Anuria B) Oliguria C) Polyuria D) Dysuria
D
When the bladder is distended with urine, it rises above the symphysis pubis and may reach to just below the umbilicus. The other choices are anatomically incorrect for assessing a distended bladder. A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine? A) Compare the amount of output with intake. B) Use a clean measuring cup for each voiding. C) Tell the client to wash the urethra before voiding. D) Wear gloves when handling a client's urine.
D
Which of the following is an indication for the use of negative pressure wound therapy? A) Bone infections B) Malignant wounds C) Wounds with fistulas to body cavities D) Pressure ulcers
D
Wound healing requires adequate proteins, carbohydrates, fats, vitamins, and minerals. Calories and proteins are necessary to rebuild cells and tissues. Vitamins C and D, zinc, and adequate fluids are also necessary for wound healing. What nursing diagnosis would be a priority for a client who has a large wound from colon surgery, is obese, and is taking corticosteroid medications? A) Self-care Deficit B) Risk for Imbalanced Nutrition C) Anxiety D) Risk for Infection
D
A Penrose drain is an open system that lacks a collection device. Jackson-Pratt drains, Hemovacs, and negative pressure dressings all utilize a suction device or collection reservoir and are considered to be closed systems. Which is an example of a closed wound? A) Abrasion B) Ecchymosis C) Incision D) Puncture wound
B
A nurse caring for a female client notes a number of laceration wounds around the cervix of the uterus due to childbirth. How could the nurse describe the laceration wound in the client's medical record? A) A clean separation of skin and tissue with a smooth, even edge B) A separation of skin and tissue in which the edges are torn and irregular C) A wound in which the surface layers of skin are scraped away D) A shallow crater in which skin or mucous membrane is missing
B
A postvoid residual (PVR) urine measures the amount of urine remaining in the bladder after voiding. It can be measured by catheterization or a bladder scan. A PVR of less than 50 mL indicates adequate bladder emptying. The nurse would document this normal finding for PVR. A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A) A clean catheter and rubber gloves B) A sterile catheterization kit or tray C) Solutions to sterilize the urethra D) Solutions to sterilize the vagina
B
Discourage the use of punishment or shame for elimination accidents. Toddlers who are toilet trained often regress and experience soiling when hospitalized, and scolding or acting disgusted only reinforces the behavior. A client is having difficulty having a bowel movement on the bedpan. What is the physiologic reason for this problem? A) It is painful to sit on a bedpan. B) The position does not facilitate downward pressure. C) The position encourages the Valsalva maneuver. D) The cause is unknown and requires further study.
B
Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a burning sensation duringurination. Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent increase in fluid intake. Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood in the urine. What is the micturition reflex? A) The process of filtration beginning with the glomerulus B) The act of bladder contraction and perceived need to void C) The reabsorption of the substances the body wants to retain D) The secretion of electrolytes that are harmful to the body
B
Kegel exercises, or pelvic floor muscle training, are used to tone and strengthen the muscles that support the bladder. They can improve voluntary control of urination and thus improve or eliminate stress incontinence. The muscles to contract are the same ones used to stop urination midstream or control defecation. The client should not contract the muscles of the abdomen, inner thigh, or buttocks while doing Kegel exercises. A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client? A) Public embarrassment B) Skin breakdown and UTI C) Inability to control urine D) Odor and leakage
B
Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation. What intervention should be included on a plan of care to prevent pressure ulcer development in health care settings? A) Change position at least once each shift. B) Implement a turning schedule every two hours. C) Use ring cushions for heels and elbows. D) Do not turn; use pressure-relieving support surface.
B
Nurses are commonly involved in scheduling diagnostic studies when a client is to undergo multiple studies. They should follow a logical sequence when more than one test is required for accurate diagnosis; that is, fecal occult blood tests to detect gastrointestinal bleeding; barium studies to visualize gastrointestinal structures and reveal any inflammation, ulcers, tumors, strictures, or other lesions; and endoscopic examinations to visualize an abnormality, locate a source of bleeding, and if necessary, provide biopsy tissue samples. A client has had frequent watery stools (diarrhea) for an extended period of time. The client also has decreased skin turgor and dark urine. Based on these data, which nursing diagnosis would be appropriate? A) Imbalanced Nutrition: Less than Body Requirements B) Deficient Fluid Volume C) Impaired Tissue Integrity D) Impaired Urinary Elimination
B
Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Results are most accurate when the client is in the supine position during the scanning. The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for this client? A) Risk for activity intolerance B) Risk for impaired skin integrity C) Risk for infection D) Risk for falls
B
Some medications, such as antibiotics, may destroy normal intestinal flora and cause diarrhea. To promote the return of normal flora, the nurse can recommend an intake of fermented dairy products, such as buttermilk or yogurt. A client is on bedrest, and an enema has been ordered. In what position should the nurse position the client? A) Fowler's B) Sims' C) Prone D) Sitting
B
The client's statement about voiding after sexual intercourse to prevent urinary tract infection is accurate. Taking frequent bubble baths, wiping the perineum from back to front, and wearing snug fitting pants increases the risk of urinary tract infection. The client should avoid taking frequent bubble baths, using harsh soaps, and wearing tight-fitting pants because they can irritate the urethra. The client also should always wipe from front to back after urinary or fecal elimination. A client is admitted to the health care facility with complaints of pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as which of the following? A) Polyuria B) Dysuria C) Nocturia D) Hematuria
B
The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation. A nurse is caring for a client who is two days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? A) Administer pain medications on a p.r.n. and regular basis. B) Assist in moving to prevent strain on the suture line. C) Tell the client that a mild fever is a normal response. D) If a scar forms over a joint, it may limit movement.
B
The most appropriate nursing diagnosis for the client is perceived constipation, because the client has made a self- diagnosis of constipation and ensures a daily bowel movement through the abuse of laxatives. Constipation may be diagnosed in a client if there is a decrease in the normal frequency of defecation accompanied by a difficult or incomplete passage of stool (and/or passage of excessively hard, dry stool). Risk of constipation can be diagnosed if a client exhibits factors that predispose him or her for developing constipation. Bowel incontinence would be indicated if the client was experiencing an involuntary passage of stool. A young woman has just consumed a serving of ice cream pie and develops severe cramping and diarrhea. The school nurse suspects the woman is ... A) Allergic to sugar B) Lactose intolerant C) Experiencing infectious diarrhea D) Deficient in fiber
B
The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse should provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are avoided and liquids are encouraged. Laxatives are also given before the procedure. During a home visit, the nurse learns that the client ensures a daily bowel movement with the help of laxatives. The client feels that deviation from a bowel movement every day is unhealthy. Which nursing diagnosis would the nurse most likely identify? A) Constipation B) Perceived constipation C) Risk of constipation D) Bowel incontinence
B
The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time. A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following? A) "I should take frequent bubble baths." B) "I need to void after sexual intercourse." C) "I should wipe from back to front after going to the bathroom." D) "I need to wear pants that are snug fitting."
B
The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence. During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? A) Urinary incontinence B) Urinary retention C) Involuntary voiding D) Urinary frequency
B
Typically, a colostomy does not produce drainage or feces until normal peristalsis returns after surgery, usually within two to five days. A nurse is providing discharge instructions for a client with a new colostomy. Which of the following is a recommended guideline for long-term ostomy care? A) During the first six to eight weeks after surgery, eat foods high in fiber. B) Drink at least two quarts of fluids, preferably water, daily. C) Use enteric-coated or sustained-release medications if needed. D) Use a mild laxative if needed.
B
The local application of cold constricts peripheral blood vessels, reduces muscle spasms, and promotes comfort. Cold reduces blood flow to tissues and decreases the local release of pain-producing substances such as histamine, serotonin, and bradykinin. This action in turn reduces the formation of edema and inflammation. Decreased metabolic needs and capillary permeability, combined with increased coagulation of blood at the wound site, facilitate the control of bleeding and reduce edema formation. Cold also reduces muscle spasms, alters tissue sensitivity (producing numbness), and promotes comfort by slowing the transmission of pain stimuli. Which of the following are functions of the skin? Select all that apply. A) Protection B) Temperature regulation C) Sensation D) Vitamin C production E) Immunological
A,B,C,E
Body piercings, radiation therapy, and diabetes place clients at risk for skin alterations. Having a homosexual relationship with multiple partners would also place a client at risk for HIV and skin alterations. Cardiac monitoring and respiratory disorders are not risk factors. A nurse is applying cold therapy to a client with a contusion of the arm. Which of the following is an effect of cold therapy? Select all that apply. A) Constricts peripheral blood vessels B) Reduces muscle spasms C) Increases blood flow to tissues D) Increases the local release of pain-producing substances E) Reduces the formation of edema and inflammation
A,B,E
Leg and foot ulcers occur from various causes, but the most common are ulcers secondary to venous insufficiency, arterial insufficiency, and neuropathy. Which of the following clients would be considered at risk for skin alterations? Select all that apply. A) A teenager with multiple body piercings B) A homosexual in a monogamous relationship C) A client receiving radiation therapy D) A client undergoing cardiac monitoring E) A client with diabetes
A,C,E
Clients who have chronic constipation and impaction, and those who are incontinent of stool, may benefit from a bowel training program. The purpose of this program is to manipulate factors within the client's control (such as exercise or fluid intake) to produce the elimination of a soft, formed stool at regular intervals without a laxative. A client tells the nurse, "I increased my fiber, but I am very constipated." What further information does the nurse need to tell the client? A) "Just give it a few more days and you should be fine." B) "Well, that shouldn't happen. Let me recommend a good laxative for you." C) "When you increase fiber in your diet, you also need to increase liquids." D) "I will tell the doctor you are having problems; maybe he can help."
C
A high-fiber diet and a daily fluid intake of 2,500 to 3,000 mL of fluids facilitate bowel elimination. Intake of the foods described makes the feces more bulky, so they move through the intestine more quickly. The stool is softer and the time to absorb toxins is decreased (toxins are believed to have a role in the development of colon cancer). A young woman comes to the emergency department with severe abdominal cramping and frequent bloody stools. Food poisoning is suspected. What diagnostic test would be used to confirm this diagnosis? A) Routine urinalysis B) Chest x-ray C) Stool sample D) Sputum sample
C
A nurse caring for a post-operative client observes the drainage in the client's closed wound drainage system. The drainage is thin with a pale pink-yellow color. The nurse documents the drainage as which of the following? A) Serous B) Sanguineous C) Serosanguineous D) Purulent
C
A physician orders a dressing to cover a wound that is shallow with minimal drainage. What would be the best type of dressing for this wound? A) Saline-moistened dressing B) Dressing secured with Montgomery straps C) Hydrocolloid dressing D) Foam dressing
C
Although all the steps listed are correct, the first step of any skill involving body fluids is to wash hands and don gloves. A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next? A) Report this abnormal finding to the physician. B) Perform another catheterization to verify the amount. C) Document this normal finding for postvoid residual. D) Palpate the abdomen for a distended bladder.
C
Although various antiseptic cleaning agents could be used to clean a wound, sterile 0.9% normal saline is usually the agent of choice. Other agents may be caustic to skin and tissues. A young man who has had a traumatic mid-thigh amputation of his right leg refuses to look at the wound during dressing changes. Which response by the nurse is appropriate? A) "Oh, for gosh sakes...it doesn't look that bad!" B) "I understand, but you are going to have to look someday." C) "I respect your wish not to look at it right now." D) "You won't be able to go home until you look at it."
C
An older adult heals more slowly than do children and adults as a result of physiologic changes of aging, resulting in diminished fibroblastic activity and circulation. Older adults are also more likely to have one or more chronic illnesses, with pathologic changes that impede the healing process. A nurse is educating a postoperative client on essential nutrition for healing. What statement by the client would indicate a need for more information? A) "I will drink a lot of orange juice and drink milk, too." B) "I will take the zinc supplement the doctor recommended." C) "I will restrict my diet to fats and carbohydrates." D) "I will drink 8 to 10 glasses of water every day."
C
Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to expel flatus from the rectum and relieve distention. Nutritive enemas are administered to replenish fluids and nutrition rectally. A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which of the following is an appropriate step in this procedure? A) Position the client in supine position as dictated by client comfort and condition. B) Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus. C) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. D) Instruct the client not to bear down while extracting feces to prevent vagal response.
C
Bowel elimination problems may also affect other areas of human functioning. For example, excessive diarrhea causes loss of body fluid, with resulting decreased skin turgor and concentrated urine. Deficient Fluid Volume is an appropriate nursing diagnosis based on the data. An infant has had diarrhea for several days. What assessments will the nurse make to identify risks from the diarrhea? A) Heart tones B) Lung sounds C) Skin turgor D) Activity level
C
Breast-fed babies have more frequent stools, and the stools are yellow to golden and loose, usually with little odor. Breast-fed babies can normally have 2 to 10 stools per day. A hospitalized toddler, previously bowel trained, has been having incontinent stools. What would the nurse tell the parents about this behavior? A) "When he does this, scold him and he will quit." B) "I don't understand why this child is losing control." C) "This is normal when a child this age is hospitalized." D) "I will have to call the doctor and report this behavior."
C
Breast-fed infants have more frequent stools, and the stools are yellow to golden, loose, and usually have little odor. With formula or cow's milk feedings, infants' stools vary from yellow to brown and are pasty in consistency. Which type of stool would the nurse assess in a client with an illness that causes the stool to pass through the large intestine quickly? A) Hard, formed B) Black, tarry C) Soft, watery D) Dry, odorous
C
