Unit 4 Urinary and Bowel elimination

During data collection of a client with bowel elimination concerns, which appropriate questions would the nurse ask? Select all that apply. "How often do you go out to eat?" "Do you use anything to help move your bowels?" "How often do you move your bowels?" "Where do you do your grocery shopping?" "Do you prefer hot foods or cold foods?"

"Do you use anything to help move your bowels?" "How often do you move your bowels?"

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question(s) will the nurse ask? Select all that apply. "Have you started a new medication?" "What are your normal bowel habits?" "Are you experiencing rectal fullness?" "Do you use laxatives?" "Is the stool difficult to pass?"

"Have you started a new medication?" "What are your normal bowel habits?" "Do you use laxatives?"

The nurse is caring for a client with a new sigmoid colostomy. The client expresses concern about how to anticipate when a bowel movement will pass into the bag. Which answer is most appropriate? "Irrigating the colostomy can help establish an elimination routine." "It is impossible to anticipate when a bowel movement will occur." "Increasing fiber in your diet will help promote regular bowel movements." "Once you recover from surgery, your bowel elimination pattern will become regular."

"Irrigating the colostomy can help establish an elimination routine."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response? "I agree; please make an appointment with your health care provider." "This only happened one time, so it is nothing to worry about." "Let's review your medication history and whether you consume bladder irritants." "I suggest that you invest in incontinence undergarments."

"Let's review your medication history and whether you consume bladder irritants."

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? 24-hour specimen clean-catch specimen random specimen intermittent specimen

24-hour specimen

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill? Warm the solution for 40 seconds in a microwave to prevent chilling the client. Assist the client to the commode or toilet to attempt a bowel movement prior to administering the enema. Administer analgesia 30 minutes before the procedure. Administer the solution gradually over 5 to 10 minutes.

Administer the solution gradually over 5 to 10 minutes.

The home care nurse visits a client and is reviewing the medications that the client uses. Which medication would the nurse identify as acting directly on the intestine to slow bowel motility, or to absorb excess fluid in the bowel? Antiflatulence agent Antidiarrheal agent Laxative Suppository

Antidiarrheal agent

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included? Encourage the client to wait to at least 30 minutes before voiding when the urge is felt. Place the client on a schedule to void every 4 hours during the daytime hours. Assist the client to a normal voiding position when possible. Explain to the client that privacy is not important with urination.

Assist the client to a normal voiding position when possible.

The nurse assesses a client who underwent abdominal surgery 72 hours prior and notes that the client has developed abdominal distention. Which further physical assessment will the nurse perform to gather additional information? Measure abdominal girth. Ask when the client last had a bowel movement. Observe the abdominal dressing. Auscultate for bowel sounds.

Auscultate for bowel sounds.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing? Take 500 mg Consume citrus fruits Drink orange and grapefruit juice Avoid more than 250 mg

Avoid more than 250 mg

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis

Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? Incontinence after the age of 3 years is not normal. Boys may take longer for daytime continence than girls. Boys may walk by 1 year and should be continent by 3 years. Daytime continence is usually not achieved by boys until age 5.

Boys may take longer for daytime continence than girls.

Which symptom will have a great impact on the extracellular fluid for water conservation? Burns Fracture Small laceration Pain

Burns

A client could experience increased urination when using which classification of medication? Cholinergic agents Analgesic medications Central nervous system depressants Stool softeners

Cholinergic agents

A nurse is collecting a stool specimen of a client suspected of having Clostridium difficile. Which guideline is recommended for this procedure? Collect 15 to 30 mL of the client's liquid stool. If portions of the stool include visible blood, mucus, or pus, discard the stool. If the specimen contains barium or enema solution, document this on the container. Refrigerate the specimen until it is cooled before sending it to the laboratory.

Collect 15 to 30 mL of the client's liquid stool.

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure? Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time. Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. Provide a light meal before the test and administer two Fleet enemas. Ensure that the client fasts 6 to 12 hours before the test as per policy.

Ensure that the client fasts 6 to 12 hours before the test as per policy.

The nurse has inserted a client's urinary catheter as ordered, but there has been no immediate flow of urine. What is the nurse's most appropriate action? Have the client take a deep breath to relax the perineal and abdominal muscles. Advance the catheter slightly, because a drainage hole may be resting against the bladder wall. Lower the head of the client's bed to increase pressure in the bladder area. Leave the catheter in place and reassess in 30 minutes.

Have the client take a deep breath to relax the perineal and abdominal muscles.

A nurse is assessing and documenting the eating habits of a client with repeated reports of gas who wants to include more fiber in the diet. Which suggestion should the nurse include in the teaching plan? Eat more cabbage and brussels sprouts to decrease gas and add fiber. Drink a soft drink daily to prevent gas and allow fiber to break down. Increase fiber slowly over a period of time to prevent gas. Include more protein in the diet to increase fiber and decrease gas.

Increase fiber slowly over a period of time to prevent gas.

Which medication causes constipation? Magnesium antacids Bisacodyl Aspirin Iron supplements

Iron supplements

A nurse is caring for a female client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action? Many clients find it embarrassing or degrading to use a bedpan. Incorrect placement of a bedpan has been linked to development of UTIs. Bedpans should not be used if the client needs to defecate. The bed should be lowered to the lowest height before placing the bedpan.

Many clients find it embarrassing or degrading to use a bedpan.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved? Glomerulus Bowman's capsule Loop of Henle Nephron

Nephron

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? Placing the client as N.P.O. status. Obtaining laboratory studies. Sitting the client up in a greater than a 40-degree angle. Notifying the health care provider of the assessment findings.

Notifying the health care provider of the assessment findings.

The nurse will place a client who is to receive a hypertonic enema solution into which position for ease of administration? Sims prone supine semi-Fowlers

Sims

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. Stop the administration of the enema and notify the physician. Stop the administration of the enema momentarily. Increase the flow of the enema until all of the solution has been administered.

Stop the administration of the enema momentarily.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? Stop the procedure and reposition the client. Slow the infusion rate, have the client take deep breaths, then resume the enema. Slow the infusion rate, withdraw the tubing slightly, then resume the enema. Stop the procedure, monitor heart rate and blood pressure.

Stop the procedure, monitor heart rate and blood pressure.

When reviewing a client's chart, which data related to a client experiencing diarrhea might suggest to the nurse a causative factor? The client returned from a foreign country 2 days ago. The client has a daily fluid intake of 2,000 to 3,000 ml. The client consumes large quantities of fresh vegetables. The client repeatedly ignores the urge to defecate.

The client returned from a foreign country 2 days ago.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions? The client may bathe rather than shower, provided the site is covered with gauze. A dressing should always be worn over the site to avoid leaking. Sterile technique must be observed by the client in the home setting. The client should avoid wearing tight clothes or belts near the site.

The client should avoid wearing tight clothes or belts near the site.

Use of an indwelling urinary catheter leads to the loss of bladder tone. True False

True

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action by the UAP is noted? UAP applies powder to the rim of the bedpan. UAP places the hand closest to the client palm up, under the lower back, and assists with lifting. UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan. UAP places a waterproof pad under the client's buttocks before placing bedpan.

UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan.

A nurse is teaching a client how to change his ostomy appliance. Which instructions should be incorporated into the teaching plan? Gently remove the pouch faceplate from the skin by pulling the appliance from the skin. If the appliance is reusable, set it aside to wash it with alcohol and allow it to air dry. Use toilet tissue to remove any excess stool from the stoma. Apply skin protectant to a 6-in (15-cm) radius around the stoma, and allow it to dry completely for 10 minutes.

Use toilet tissue to remove any excess stool from the stoma.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately? Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. Obtained urine specimen from urinary drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port. Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure.

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.

A student nurse studying human anatomy knows that a structure of the large intestine is the: duodenum jejunum ileum cecum

cecum

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? checking that the client has signed a consent form for the procedure explaining to the client that the procedure will be painful maintaining the client without liquids before the procedure inserting a Foley catheter the morning of the procedure

checking that the client has signed a consent form for the procedure

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, dark amber strongly aromatic, amber

cloudy, foul odor

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence? stress urge functional total

functional

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel? tap water mineral oil water, soap hypertonic saline

hypertonic saline

Digital rectal examination confirms that a client has an impaction, and an enema solution has been ordered to lubricate the stool and intestinal mucosa without distending the intestine. What solution best meets this client's needs? water soap normal saline oil

oil

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion? inability to control either urinary or bowel elimination hygiene measures used to keep meatus and adjacent area of the catheter clean use of a catheter to collect urine in a sterile environment one or both of the ureters are surgically implanted elsewhere

one or both of the ureters are surgically implanted elsewhere

The nurse is planning care for a client with a newly placed urostomy. For what priority problems will the nurse address and provide interventions? Select all that apply. urinary retention reflex urinary incontinence impaired urinary elimination situational low self-esteem risk for infection

situational low self-esteem risk for infection

When educating a breastfeeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be: green. yellow. beige. brown.

yellow.