Urinary and Bowel Elimination
A patient has not had a bowel movement for 4 days. Now she has nausea and severe cramping throughout her abdomen. On the basis of these findings, what should the nurse suspect? A. An intestinal obstruction B. Irritation of the intestinal mucosa C. Gastroenteritis D. A fecal impaction
A. An intestinal obstruction Correct
A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented prior to the test? (Select all that apply.) A. Ask the patient about any allergies and reactions. B. Instruct the patient that a full bladder is required for the test. C. Instruct the patient to save all urine in a special container. D. Ensure that informed consent has been obtained.
A. Ask the patient about any allergies and reactions. Correct D. Ensure that informed consent has been obtained. Correct
Before collecting a stool sample for occult blood, the nurse instructs the nursing assistive personnel to: A. Ask the patient to void. B. Wash the patient's perineum. C. Secure a sterile, specimen container. D. Plan to collect the first specimen of the day.
A. Ask the patient to void. Correct
Which of the following medications listed in a patient's medication history possibly causes gastrointestinal bleeding? (Select all that apply.) A. Aspirin B. Cathartics C. Antidiarrheal opiate agents D. Nonsteroidal antiinflammatory drugs (NSAIDs)
A. Aspirin Correct D. Nonsteroidal antiinflammatory drugs (NSAIDs) Correct
What best describes measurement of post-void residual (PVR)? A. Bladder scan the patient immediately after voiding. B. Catheterize the patient 30 minutes after voiding. C. Bladder scan the patient when they report a strong urge to void. D. Catheterize the patient with a 16 Fr/10 mL catheter
A. Bladder scan the patient immediately after voiding. Correct
Which of the following symptoms are warning signs of possible colorectal cancer according to the American Cancer Society guidelines? (Select all that apply.) A. Change in bowel habits B. Blood in the stool C. A larger-than-normal bowel movement D. Fecal impaction E. Muscle aches F. Incomplete emptying of the colon G. Food particles in the stool H. Unexplained abdominal or back pain
A. Change in bowel habits Correct B. Blood in the stool Correct F. Incomplete emptying of the colon Correct H. Unexplained abdominal or back pain Correct
Since removal of the patient's Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first? A. Check for bladder distention B. Encourage fluid intake C. Obtain an order to recatheterize the patient D. Document the amount of each voiding for 24 hours
A. Check for bladder distention Correct
A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is: A. Cystitis. B. Hematuria. C. Pyelonephritis. D. Dysuria.
A. Cystitis. Correct
Which skills must a patient with a new colostomy be taught before discharge from the hospital? (Select all that apply.) A. How to change the pouch B. How to empty the pouch C. How to open and close the pouch D. How to irrigate the colostomy E. How to determine if the ostomy is healing appropriately
A. How to change the pouch Correct B. How to empty the pouch Correct C. How to open and close the pouch Correct E. How to determine if the ostomy is healing appropriately Correct
Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (Select all that apply.) A. Incontinence Correct B. Frequency Correct C. Urgency Correct D. Urinary retention Correct E. Urinary tract infection Correct
A. Incontinence Correct B. Frequency Correct C. Urgency Correct D. Urinary retention Correct E. Urinary tract infection Correct
A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (Select all that apply.) A. Infection. B. Retention. C. Stagnant urine. D. Reflux of urine.
A. Infection. Correct D. Reflux of urine. Correct
What should the nurse teach a young woman with a history of urinary tract infections about UTI prevention? (Select all that apply.) A. Keep the bowels regular. B. Limit water intake to 1-2 glasses a day C. Wear cotton underwear D. Cleanse the perineum from front to back. E. Practice pelvic muscle exercise (Kegel) daily.
A. Keep the bowels regular. Correct C. Wear cotton underwear Correct D. Cleanse the perineum from front to back. Correct
The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.) A. Note any allergies. Correct B. Monitor intake and output. C. Provide for perineal hygiene. D. Assess vital signs. E. Encourage fluids after the procedure. Correct
A. Note any allergies. Correct E. Encourage fluids after the procedure. Correct
A patient is admitted for lower gastrointestinal (GI) bleeding. What color of stool does the nurse anticipate the patient to have? A. Red B. Black C. Green D. Orange
A. Red Correct
During the administration of a warm tap-water enema, the patient complains of cramping abdominal pain that he rates 6 out of 10. What is the first thing the nurse should do? A. Stop the instillation B. Ask the patient to take deep breaths to decrease the pain C. Add soapsuds to the enema D. Tell the patient to bear down as he would when having a bowel movement
A. Stop the instillation Correct
A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void? A. Suggest he stand at the bedside B. Stay with the patient C. Give him the urinal to use in bed D. Tell him that, if he doesn't urinate, he will be catheterized
A. Suggest he stand at the bedside Correct
Which of the following is the correct order for insertion of an indwelling catheter in a female patient? 1. Insert and advance catheter. 2. Lubricate catheter. 3. Inflate catheter balloon. 4. Cleanse urethral meatus. 5. Drape the patient with the sterile square and fenestrated drapes. 6. When urine appears advance another 2.5 to 5 cm. 7. Prepare sterile field and supplies. 8. Gently pull catheter until resistance is felt. 9. Attach drainage tubing. A. 7, 5, 2, 1, 4, 6, 3, 8, 9 B. 5, 7, 2, 4, 1, 6, 3, 8, 9 C. 5, 7, 1, 2, 4, 6, 3, 9, 8 D. 5, 7, 2, 1, 4, 3, 6, 8, 9
B. 5, 7, 2, 4, 1, 6, 3, 8, 9 Correct
The nurse should do which of the following when placing a bedpan under an immobilized patient? A. Lift the patient's hips off the bed and slide the bedpan under the patient B. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle C. Adjust the head of the bed so it is lower than the feet and use gentle but firm pressure to push the bedpan under the patient D. Have the patient stand beside the bed and then have him or her sit on the bedpan on the edge of the bed
B. After positioning the patient on the bedpan, elevate the head of the bed to a 45-degree angle Correct
Which nursing interventions should the nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) A. Attach a 3 mL syringe to the inflation port B. Allow the balloon to drain into the syringe by gravity. C. Initiate a voiding record/bladder diary D. Pull catheter quickly E. Clamp the catheter prior to removal.
B. Allow the balloon to drain into the syringe by gravity. Correct C. Initiate a voiding record/bladder diary Correct
The NAP reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? A. Implement the "as needed" order to irrigate the catheter. B. Assess the catheter and drainage tubing for obvious occlusion. C. Notify the health care provider immediately. D. Assess the vital signs and intake and output record.
B. Assess the catheter and drainage tubing for obvious occlusion. Correct
bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? A. Increase the rate of the CBI B. Assess the intake and output C. Decrease the rate of the CBI D. Assess vital signs
B. Assess the intake and output Correct
The nurse notes that the patient's Foley catheter bag has been empty for 4 hours. The priority action would be to: A. Irrigate the Foley. B. Check for kinks in the tubing. C. Notify the health care provider. D. Assess the patient's intake.
B. Check for kinks in the tubing. Correct
Which of the following may cause Clostridium difficile infection? (Select all that apply.) A. Chronic laxative use B. Contact with C. difficile bacteria C. Overuse of antibiotics D. Frequent episodes of diarrhea caused by food intolerance E. Inflammation of the bowel
B. Contact with C. difficile bacteria Correct C. Overuse of antibiotics Correct
An elderly patient comes to the hospital with a complaint of severe weakness and diarrhea for several days. Of the following problems, which is the most important to assess initially? A. Malnutrition B. Dehydration C. Skin breakdown D. Incontinence
B. Dehydration Correct
The nurse is caring for a 78-year-old man with diarrhea. Of the following problems, which is the most important to consider? A. Malnutrition B. Dehydration C. Skin breakdown D. Incontinence
B. Dehydration Correct
What nursing intervention decreases the risk for catheter associated urinary tract infection (CAUTI)? A. Cleanse the urinary meatus 3-4 times daily with antiseptic solution. B. Hang the urinary drainage bag below the level with the bladder. C. Empty the urinary drainage bag daily. D. Irrigate the urinary catheter with sterile water.
B. Hang the urinary drainage bag below the level with the bladder. Correct
There is no urine when a catheter is inserted into a female's urethra. What should the nurse do next? A. Remove the catheter and start all over with a new kit and catheter. B. Leave the catheter there and start over with a new catheter. C. Pull the catheter back and re-insert at a different angle. D. Ask the patient to bear down and insert the catheter further.
B. Leave the catheter there and start over with a new catheter. Correct
An ambulatory elderly woman with dementia is incontinent of urine. She has poor short term memory and has not been seen toileting independently. What is the best nursing intervention for this patient? A. Recommend she be evaluated for an OAB medication. B. Start a scheduled toileting program. C. Recommend she be evaluated for an indwelling catheter. D. Start a bladder retraining program The first nursing intervention for any patient with incontinence, who is able to toilet, is to assist them with toilet access. This patient is not cognitively intact so a bladder retraining program is not appropriate for her. It is not clear in this case that she has OAB and a catheter is never a good solution for incontinence.
B. Start a scheduled toileting program. Correct
The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states: A. "I will perform my Kegel exercises every day." B. "I joined weight watchers." C. "I drink two glasses of wine with dinner." D. "I have tried urinating every 3 hours."
C. "I drink two glasses of wine with dinner." Correct
The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by: A. 1400. B. 1600 C. 1700. D. 2300.
C. 1700. Correct
What is a critical step when inserting an indwelling catheter into a male patient? A. Slowly inflate the catheter balloon with sterile saline. B. Secure the catheter drainage tubing to the bed sheets C. Advance the catheter to the bifurcation of the drainage and balloon ports. D. Advance the catheter until urine flows, then insert ¼ inch more.
C. Advance the catheter to the bifurcation of the drainage and balloon ports. Correct
When assessing a 55-year-old patient who is in the clinic for a routine physical, the nurse instructs the patient about the need to obtain a stool specimen for guaiac fecal occult blood testing (gFOBT): A. If patient reports rectal bleeding. B. When there is a family history of polyps. C. As part of a routine examination for colon cancer. D. If a palpable mass is detected on digital examination.
C. As part of a routine examination for colon cancer. Correct
The patient is incontinent, and a condom catheter is placed. The nurse should take which action? A. Secure the condom with adhesive tape B. Change the condom every 48 hours C. Assess the patient for skin irritation D. Use sterile technique for placement
C. Assess the patient for skin irritation Correct
Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? A. Do you leak urine when you cough or sneeze? B. Do you need help getting to the toilet? C. Do you dribble urine constantly? D. Does it burn when you pass your urine? Incontinence characterized by constant dribbling of urine is associated with incontinence associated with urinary retention. . The other options point to stress incontinence, functional incontinence or a UTI.
C. Do you dribble urine constantly? Correct
The nurse is taking a health history of a newly admitted patient with a diagnosis of possible fecal impaction. Which of the following is the priority question to ask the patient or caregiver? A. Have you eaten more high-fiber foods lately? B. Are your bowel movements soft and formed? C. Have you experienced frequent, small liquid stools recently? D. Have you taken antibiotics recently? Frequent or continuous oozing of liquid stools occurs
C. Have you experienced frequent, small liquid stools recently? Correct
Nurses discourage patients from straining on defecation primarily because it causes: (Select all that apply.) A. Pain. B. Impaction. C. Hemorrhoids. D. Dysrhythmias.
C. Hemorrhoids. Correct D. Dysrhythmias. Correct
When a patient has fecal incontinence as a result of cognitive impairment, it may be helpful to teach caregivers to do which of the following interventions? A. Cleanse the skin with antibacterial soap and apply talcum powder to the buttocks B. Use diapers and heavy padding on the bed C. Initiate bowel or habit training program to promote continence D. Help the patient to toilet once every hour
C. Initiate bowel or habit training program to promote continence Correct
During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with: A. Food allergy. B. Irritable bowel. C. Lactose intolerance. D. Increased peristalsis.
C. Lactose intolerance. Correct
When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? A. Pale yellow urine B. Slightly cloudy urine C. Light pink urine Correct D. Dark amber urine
C. Light pink urine Correct
The nurse is teaching the patient to obtain a specimen for fecal occult blood testing using fecal immunochemical (FIT) testing at home. How does the nurse instruct the patient to collect the specimen? A. Three fecal smears from one bowel movement B. One fecal smear from an early-morning bowel movement C. One fecal smear from three separate bowel movements D. Three fecal smears when blood can be seen in the bowel movement
C. One fecal smear from three separate bowel movements Correct
The nurse understands that, when comparing nasogastric tubes used for gastric decompression, a Salem sump is specifically designed to: A. Minimize the risk of a bowel obstruction. B. Ensure drainage of the intestines. C. Prevent gastric mucosal damage. D. Promote resting the gut.
C. Prevent gastric mucosal damage. Correct
What instructions should the nurse give the NAP concerning a patient who has had an indwelling urinary catheter removed that day? A. Limit oral fluid intake to avoid possible urinary incontinence. B. Expect patient complaints of suprapubic fullness and discomfort. C. Report the time and amount of first voiding. D. Instruct patient to stay in bed and use a urinal or bedpan.
C. Report the time and amount of first voiding. Correct
The nurse is caring for a patient with a colostomy. Which intervention is most important? A. Cleansing the stoma with hot water B. Inserting a deodorant tablet in the stoma bag C. Selecting a bag with an appropriate-size stoma opening D. Wearing sterile gloves while caring for the stoma
C. Selecting a bag with an appropriate-size stoma opening Correct
The nurse is caring for a patient with an ileostomy. Which intervention is most important? A. Cleansing the stoma with hot water B. Inserting a deodorant tablet in the stoma bag C. Selecting or cutting a pouch with an appropriate-size stoma opening D. Wearing sterile gloves while caring for the stoma
C. Selecting or cutting a pouch with an appropriate-size stoma opening Correct
The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to: A. Use the double-voiding technique. B. Perform Kegel exercises. C. Use Credé's method. D. Keep a voiding diary.
C. Use Credé's method. Correct
The nurse is taking a health history of a newly admitted patient with a diagnosis Rule/out bowel obstruction. Which of the following is the priority question to ask the patient? A. Describe your bowel movements. B. How often do you have a bowel movement? C. When was the last time you moved your bowels? D. Do you routinely use stool softeners, laxatives, or enemas?
C. When was the last time you moved your bowels? Correct
After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output?
Correct Responses: "The output is determined by calculating the amount of irrigation solution and subtracting that from the total output: 150 × 8 = 1200. Total output is 2520. 2520 - 1200 = 1320 urine output., 1320 mL, 1320 mL, The output is determined by calculating the amount of irrigation solution and subtracting that from the total output: 150 × 8 = 1200. Total output is 2520. 2520 - 1200 = 1320 urine output."
What is the correct order for an ostomy pouch change? 1. Close the end of the pouch. 2. Measure the stoma. 3. Cut the hole in the wafer. 4. Press the pouch in place over the stoma. 5. Remove the old pouch. 6. Trace the correct measurement onto the back of the wafer. 7. Assess the stoma and the skin around it. 8. Cleanse and dry the peristomal skin. A. 5, 8, 2, 7, 3, 6, 4, 1 B. 8, 5, 6, 2, 7, 3, 4, 1 C. 8, 5, 7, 6, 2, 3, 4, 1 D. 5, 8, 7, 2, 6, 3, 4, 1
D. 5, 8, 7, 2, 6, 3, 4, 1 Correct
Match the following steps for administering a prepackaged enema with the correct order in which they occur. 1. Insert enema tip gently in the rectum. 2. Help patient to bathroom when he or she feels urge to defecate. 3. Position patient on side. 4. Perform hand hygiene and apply clean gloves. 5. Squeeze contents of container into rectum. 6. Explain procedure to the patient. A. 6, 3, 4, 1, 5, 2 B. 6, 4, 1, 3, 2, 5 C. 4, 6, 3, 1, 2, 5 D. 6, 4, 3, 1, 5, 2
D. 6, 4, 3, 1, 5, 2 Correct
A cleansing enema is ordered for a 55-year-old patient before intestinal surgery. The nurse understands that the maximum amount of fluid given is: A. 150 to 200 mL. B. 200 to 400 mL. C. 400 to 750 mL. D. 750 to 1000 mL.
D. 750 to 1000 mL. Correct
The nurse recognizes which patient needs to use a fracture pan for a bowel movement? A. The patient who is obese B. The patient experiencing confusion C. The patient on bed rest D. A patient recovering from hip surgery
D. A patient recovering from hip surgery Correct
An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to: A. Help him stand to void. B. Place a condom catheter. C. Have him practice Credé's method. D. Initiate Kegel exercises.
D. Initiate Kegel exercises. Correct
During the nursing assessment a patient reveals that he has diarrhea and cramping every time he has ice cream. He attributes this to the cold nature of the food. However, the nurse begins to suspect that these symptoms are associated with what problem? A. Food allergy B. Irritable bowel C. Increased peristalsis D. Lactose intolerance
D. Lactose intolerance Correct
A patient starts to experience pain while receiving an enema. The nurse notes blood in the return fluid and rectal bleeding. What action does the nurse take first? A. Administers pain medication B. Slows down the rate of instillation C. Tells the patient to breathe slowly and relax D. Stops the instillation and obtains vital signs
D. Stops the instillation and obtains vital signs Correct
The postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first? A. Encourage fluid intake B. Administer pain medication C. Catheterize the patient D. Turn on the bathroom faucet as he tries to void
D. Turn on the bathroom faucet as he tries to void Correct
Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? A. Leave a gap of 3-5 inches between the tip of the penis and drainage tube B. Shave the pubic area so that hair does not adhere C. Wash with soap and water prior to applying the condom type catheter. Correct D. Apply tape to the condom sheath to keep it securely in place.
Hygiene minimizes skin irritation. There needs to be 2.5 to 5 cm (1 to 2 inches) of space between tip of the glans penis and the end of the catheter. Excess space may cause pooling of urine causing excessive exposure to urine. Shaving the pubic area increases the risk for skin irritation. The condom should be secure but not tight. Application of tape is contraindicated because it could interfere with circulation increasing risk for necrosis of the penis.
