UPNS 200 Exam 3 Fundamentals Study Guide 2020 – Duquesne university | UPNS200 Exam 3 Fundamentals Study Guide 2020

Document Content and Description Below

UPNS 200 Exam 3 Fundamentals Study Guide 2020 – Duquesne university Exam 3 Fundamentals Study Guide EAQ QUIZ A residual urine test is prescribed for a client with benign prostatic hyperplasia... . What should the nurse instruct the client to do? Void after a urinary catheter is removed. Collect a specimen of urine during midstream. Attempt to void when a urinary catheter is in place. Empty the bladder before a urinary catheter is inserted. Emptying the bladder before a urinary catheter is inserted measures how much urine remains in the bladder after voiding. Residual urine is the urine left in the bladder after urinating. After voiding, the client is catheterized, or a bladder scan can be used. The bladder will be empty of urine when the urinary catheter is removed. Collecting a specimen of urine during midstream is known as a clean-catch, or midstream, urine specimen, not a residual urine test. The urinary catheter will prevent urine accumulation. A primary healthcare provider prescribed an indwelling urinary catheter for a client. Which catheter should the nurse use to implement this prescription? Option C is an indwelling urinary catheter[1][2]; it has two lumens. One lumen is used to inflate the balloon at the tip of the catheter; this holds the catheter in place. The other lumen allows the continuous drainage of urine from the bladder via gravity into a collection bag. Option A is a simple one-lumen urethral catheter. It is used to empty the bladder of urine or to obtain a sterile urine specimen. It is inserted once, removed, and discarded. Option B is a mushroom-tipped Pezzar catheter that is used for suprapubic catheterization. Option D is a triple-lumen urinary catheter; it is used for continuous bladder irrigations. One lumen is used to inflate the balloon at the tip of the catheter. The second lumen is used to continuously instill a solution into the bladder. The third lumen allows the continuous drainage of fluid from the bladder via gravity into a collection bag. What is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs)? Removing the catheter Keeping the drainage bag off of the floor Washing hands before and after assessing the catheter Cleansing the urinary meatus with soap and water daily Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs). Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs. The nurse understands that the best way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? Perform catheter care twice a day. Replace the catheter on a routine basis. Administer cranberry tablets three times each day. Give antibiotics for the duration of catheter placement. A bacterial biofilm develops in long-term indwelling catheters increasing the risk of catheter-associated urinary tract infection (CAUTI). The best way to eliminate this risk is to perform routine perineal hygiene and catheter care every day. Routine replacement of indwelling urinary catheters increases CAUTI risk. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm. A nurse is caring for an older bedridden male client who is incontinent of urine. Which action should the nurse take first? Restrict fluid intake. Offer the urinal regularly. Apply incontinence pants. Insert an indwelling urinary catheter. Offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence; also it promotes skin breakdown and can lower self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection. Also, it requires a primary healthcare provider’s prescription. A urine specimen is needed to test for the presence of ketones in a diabetic client. What should the nurse do when collecting this specimen from a urinary catheter? Disconnect the catheter, and drain the urine into a clean container. Clean the drainage valve, and remove the urine from the catheter bag. Wipe the catheter with alcohol, and drain the urine into a sterile test tube. Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine. The urinary catheter and drainage bag should always remain a closed, sterile system; urine should be drawn only from the catheter port, not the collection bag. Cleaning the drainage valve and removing the urine from the catheter bag will not yield a fresh specimen indicating present acetone levels. The system should remain closed so that fewer microorganisms enter the urinary tract. A client is admitted to the hospital with urinary retention, and an indwelling urinary catheter is prescribed by the primary healthcare provider. What should the nurse do to help prevent the client from developing a urinary tract infection? Assess urine specific gravity. Collect a weekly urine specimen. Maintain the prescribed hydration. Empty the drainage bag once a day. Promoting hydration maintains urine production that flushes the bladder, thereby preventing urinary stasis and possible infection. Although assessing urine specific gravity may help identify a urinary tract infection, it will not prevent it. Although collecting a weekly urine specimen for culture and sensitivity may help identify a urinary tract infection, it will not prevent it. The collection bag is emptied once every shift unless the bag is full and needs to be emptied sooner. What instruction regarding sample collection should the nurse give a client who is ordered a clean-catch urine specimen? Urinate small amount, stop flow, fill half of cup Collect the last urine sample voided in the night Keep the urine sample in dry warm area if delay is anticipated Send the urine sample to the laboratory within 6 hours of collection The nurse instructs the client to always collect the midstream urine to send as a test specimen. The client should be instructed to cleanse the perineum with the wipe provided, urinate a small amount, and then stop the flow. The client should then position the specimen cup a few inches from the urethra and resume urination, filling the cup at least half way. The client is asked to collect the first sample voided in the morning because the urine is highly concentrated in the morning. Keeping the urine sample in the refrigerator helps reduce bacterial growth due to alkaline environment. The cells in the urine sample begin to break down in alkalinity, and therefore the client is instructed to send the sample to the laboratory as soon as collected. A 24-hour urine test is prescribed for a client who has a tentative diagnosis of pheochromocytoma. What should the nurse do first? Start the time of the test after discarding the first voiding. Discard the last voiding in the 24-hour time period for the test. Insert a urinary retention catheter to promote the collection of urine. Strain the urine following each voiding before adding the urine to the container. The first voiding is discarded because that urine was in the bladder before the test began and should not be included. The last voiding should be placed in the specimen container because the urine was produced during the 24-hour time frame of the test. Discarding the last void in the 24-hour time period for the test is not necessary; voided specimens are acceptable. Straining the urine following each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi. The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen? "Start urinating in the cup and then finish urinating in the toilet." "If you can’t fill the cup then leave it on the toilet and use it again when you next void." "With the enclosed towelettes, wipe your labia from front to back before collecting the specimen." "When you finish, leave the cup on the back of the toilet and the aide will get it when making rounds." The client must use the packaged towelettes and wipe the labia from front to back before urinating. The client needs to urinate a small amount in the toilet first and then hold the cup under the perineal area and finish urinating in the cup. If the client cannot void enough for a specimen, the insufficient sample should be discarded and another specimen obtained when the client can void a sufficient amount. The client should notify the nurse immediately after the specimen is collected so it can be sent to the laboratory for analysis. A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. "I may eat potatoes at dinner daily." "I should drink at least six glasses of water every day." "I must eat eggs for breakfast three times a week." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen." At least six glasses of water keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipation. Walking increases intestinal motility, which helps prevent constipation. Potatoes and eggs do not contain roughage and will not prevent constipation. A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? Presence of distention Extent of weight gained Amount of high-fiber food consumed Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to constipation, particularly in clients with limited activity or an inadequate fluid intake, the lack of bulk in the diet is not the most significant information to obtain at this time. A client is admitted to the hospital for medical treatment of bronchopneumonia. Which test result should the nurse examine to help determine the effectiveness of the client's therapy? Bronchoscopy Pulse oximetry Pulmonary function studies Culture and sensitivity tests of sputum The aim of therapy is to eliminate the causative agent, which is determined from culture and sensitivity tests of sputum. Bronchoscopy shows the appearance of the bronchi but does not indicate the presence or absence of microorganisms. Pulse oximetry is used to assess for hypoxemia; it does not provide data on the condition of the lung tissue itself or on the presence or absence of microorganisms. Pulmonary function studies indicate air volume that may be within the expected range despite the presence of bronchopneumonia. On the second day after an abdominoperineal resection, the nurse anticipates that the colostomy stoma will have what appearance? Dry, pale pink, and flush with the skin Moist, red, and raised above the skin surface Dry, purple, and depressed below the skin surface Moist, pink, flush with the skin, and painful when touched The surface of a stoma is mucous membrane and should be dark pink to red, moist, and shiny; the stoma usually is raised beyond the skin surface. The stoma should be moist, not dry; pale pink indicates a low hemoglobin level. Although some stomas can be flush with the skin, a raised stoma is more common. The stoma should be moist, not dry; purple indicates compromised circulation. A depressed stoma is retracted and unexpected. Although the stoma should be moist and dark pink to red, it should not be painful; although some stomas can be flush with the skin, a raised stoma is more common. The nurse is providing postoperative care 8 hours after a client had a total cystectomy and the formation of an ileal conduit. Which assessment finding should be reported immediately? Edematous stoma Dusky-colored stoma Absence of bowel sounds Pink-tinged urinary drainage A dusky-colored stoma may denote a compromised blood supply to the stoma and impending necrosis. An edematous stoma and absence of bowel sounds are expected in the early postoperative period after this surgery. Pink-tinged urine may be present in the immediate postoperative period. A client appears depressed since the surgical creation of a colostomy five days ago. The nurse determines that there is some movement toward adaptation to the change in body image when the client exhibits which behavior? Discusses the necessity of the colostomy Requests the nurse to change the dressing Looks at the face of the nurse during care Stares at the stoma during dressing changes A willingness to view the stoma indicates the beginning of acceptance and integration of the colostomy into the body image. Discussing the necessity of the colostomy is evidence of intellectualization rather than acceptance of the change in body image. Requesting the nurse to change the dressing indicates lack of readiness to participate in the care of the stoma. Watching the face of the nurse during the care indicates that the client is observing the staff's response to and acceptance of the stoma and, by extension, the client as an individual. A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client? Wound infection Ischemia of the stoma Electrolyte imbalances Excoriation of skin around the stoma An ileostomy directs liquid feces out of the body, bypassing the large intestine, where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although a wound infection is always a possibility after surgery, it is unlikely and not life threatening. Although the stoma should be assessed to ensure that it is not dark, but pink and moist, which indicates adequate circulation, this complication is unlikely and not life threatening. Although impaired skin integrity can occur when liquid feces remain on the skin surrounding the stoma, this should not occur if an appliance to collect the discharge is used correctly. Also, impaired skin integrity is not a life-threatening complication. When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility. Which represents appropriate nursing management of the client's nasogastric (NG) tube in the immediate postoperative period following gastroduodenostomy? Advancing the tube to the original insertion depth if the tube becomes dislodged. Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted. Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period. Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. Advancing the tube to the original insertion depth if the tube becomes dislodged is not recommended. Improper reinsertion may result in the aspiration of gastric contents. Vigorous irrigation of the nasogastric tube, even if clogged, is not recommended because this can cause damage to the gastric mucosa. Finally, the presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period. Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? Choking Redness Gagging Cyanosis If the nasogastric tube is passed accidentally into the trachea rather than the esophagus, it will obstruct the airway, causing cyanosis; this is a serious problem that must be corrected immediately. Choking may occur as the tube passes through the back of the throat; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Facial flushing (floridity) may result if the client attempts to fight the passage of the tube; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Gagging may occur as the tube passes from the nasal passage through the pharynx; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? Empty feeding bag stays attached to the tubing. Tube is flushed with air after medication is given. Replacement of the tube is done on a weekly basis. Head of the bed remains elevated after the feeding. The client's upper body must be elevated to prevent aspiration and promote digestion. Attaching the empty feeding bag to the tubing is not necessary. The end of the gastrostomy tube just needs to be covered. The tube is flushed with water, not air, before and after food or medication is given; excess air in the gastrointestinal tract can cause abdominal distention and cramping. Because the tube was inserted by a surgical procedure, it is replaced only when a problem is identified, and usually only by the healthcare provider. The nurse is instructing the student nurse how to administer percutaneous enterostomal gastrostomy (PEG) tube feeding to a client. What should the nurse tell the student? Select all that apply. Keep the client's head of bed elevated at least 10 degrees. Connect tube feeding bag to client and feeding pump. Flush with warm water before beginning feeding. Check prescription for correct client formula. Set correct rate and initiate pump. Check for diarrhea. Connect the feeding bag to the client and pump and check for any residual feeding before initiating the feeding. Always check the most recent tube feeding prescription before initiating feeding. Flush the PEG tube with 30 mL of warm water and set correct rate on pump and begin feeding. Diarrhea is a complication of tube feedings and should be assessed. The client's head of bed needs to be elevated at least 30 degrees. Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply. Encouraging regular dental checkups Facilitating smoking cessation programs Administering influenza vaccines to older adults Teaching the procedure for breast self-examination Referring clients with a chronic illness to a support group Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists. A registered nurse is educating a nursing student about the primary level of prevention. What information should the nurse provide? Select all that apply. Primary prevention is also known as true prevention. Primary prevention is applied to clients who are considered physically and emotionally healthy. Primary prevention is directed towards rehabilitative care rather than diagnosis and treatment. Primary prevention activities enable clients to return to a normal level of health as early as possible. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities. Primary prevention is also known as true prevention as it precedes disease and dysfunction. Primary prevention is applied on those clients who are considered to be physically and emotionally healthy. Primary prevention focuses on health promotion. This includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention is directed towards providing rehabilitative care to clients rather than diagnosis and treatment. Secondary prevention activities enable clients to return to a normal level of health as early as possible. A nurse is educating a client about the tertiary level of prevention. What information should the nurse provide? Select all that apply. Tertiary prevention focuses on preventing complications of illness. Tertiary prevention helps clients achieve as high a level of functioning as possible. Tertiary prevention aims at minimizing the effects of long-term disease or disability. Tertiary prevention is applied when the client is physically and emotionally healthy. Tertiary prevention activities are aimed at diagnosis and treatment instead of rehabilitation. Tertiary prevention is also known as preventive care since it aims at preventing further disability or reduced functioning in the clients. Even though clients may have developed limitations due to illness or impairment, tertiary prevention helps in achieving as high a level of functioning as possible. Tertiary prevention makes use of interventions that prevent complications and deteriorations in order to minimize the effects of long-term disease or disability. Tertiary prevention is applied when the client has a defect or disability that is permanent and irreversible. Tertiary prevention activities focus on rehabilitative care instead of diagnosis and treatment. The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? Planning Evaluation Assessment Implementation The basic step implementation involves performing nursing care therapies and including the client as an active participant in the care. Planning involves nursing processes such as developing an individualized care plan. Evaluation involves nursing processes such as identifying the success in meeting desired outcomes. Assessment involves nursing processes such as collecting data about a client’s physical, psychological, social culture. A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? Evaluation Assessment Nursing interventions Proposed nursing care An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client’s assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned. Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis? Planning Evaluation Assessment Implementation The planning phase of the nursing process is directly affected if the nurse does not make a nursing diagnosis. The nurse cannot plan or interpret correctly if the client’s problems are not clear. The evaluation phase of the nursing process is not directly affected by the nursing diagnosis. A nursing diagnosis is based on an accurate assessment. The nurse must obtain and document a comprehensive assessment. In the absence of nursing diagnosis, the nurse cannot implement appropriate nursing interventions. The implementation phase is directly affected if there is no plan of care. Which step in the nursing process would involve promoting a safe environment for the client? Planning Diagnosis Assessment Implementation The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client’s health and situation during the assessment stage. A nurse is evaluating a client’s response to fluid replacement therapy. Which clinical finding indicates successful replacement? Urinary output of 30 mL in an hour Central venous pressure reading of 1.5 mm Hg Baseline pulse rate of 120 beats/min that decreases to 110 beats/min within a 15-minute period Baseline blood pressure of 50/30 mm Hg that increases to 70/40 mm Hg within a 30-minute period A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 1.5 mm Hg indicates hypovolemia. A baseline pulse rate of 120 beats/min that decreases to 110 beats/min within a 15-minute period and a baseline blood pressure of 50/30 mm Hg that increases to 70/40 mm Hg within a 30-minute period indicate improvement but not necessarily adequate tissue perfusion. Chapter 46- Urinary Elimination Organs of the Urinary System: • Kidneys- remove waste from the blood to form urine • Ureters- transport urine from the kidneys to the bladder • Bladder- reservoir for urine until the urge to urinate develops • Urethra- urine travels from the bladder and exits through the urethral meatus Physical Assessment: • Skin and mucosal membranes o Asses hydration • Kidneys o Flank pain may occur with infection or inflammation • Bladder o Distended bladder rises above symphysis pubis • Urethral Meatus o Observer for discharge, inflammation, and lesions Assessment of Urine: • Intake and output- 30 mL/hr as minimum • Color- pale straw to amber color • Clarity- assessing for bacteria, protein, and blood; transparent unless pathology is present • Odor- ammonia in nature Common Urinary Problems • Urinary retention- accumulation of urine due to the inability of the bladder to empty; patients feel pressure, discomfort, and pain o PVR (post void residual)- the amount of urine left in the bladder after voiding • Urinary tract infection- bacteria in urinary tract; can result from catheterization or procedure; most common HAI; E. Coli found in colon is the most common causative pathogen; treated with antibiotics • Urinary incontinence- involuntary leakage of urine • Urinary diversions- diversion of urine to external source o Care- inspect the client’s stoma regularly; keep skin dry and clean; measure input and outputs; watch for mucous in the urine from an ileal conduit; make sure patient can participate in care • Hematuria- blood in urine • Pyelonephritis- kidney infection Indications for Use of Bladder Scanner: • Urinary frequency • Absent or decreased urine output • Bladder distention • Inability to void • Establishing intermittent catherization schedule Factors that affect urination- can be acute (reversible) or chronic (irreversible): • Pre-renal: decreased blood flow to and through the kidneys • Renal: disease condition of the renal tissue • Post-renal: obstruction in the lower urinary tract that prevents blood flow from the kidneys • Diseases that affect urination: o Diabetes mellitus o Multiple sclerosis o BPH o Alzheimer’s disease o Parkinson’s disease o Degenerative joint disease • Psychological factors like anxiety and emotional stress • Fluid balances maintain the balance between retention and excretion of fluids • Caffeine increases urine formation and alcohol increases water loss in urine • Fever causes highly concentrated and reduced urine volume Types and uses of urethral catheters: • Intermittent ureteral catheters- used to drain bladder for shorter periods (5 to 10 minutes) • Indwelling urethral catheter- used to when catheter is to remain in place for continuous drainage; designed using an inflated balloon so it does not slip out of bladder Nursing Care: • With indwelling catheters, specimens are collected without opening the drainage system using a special port in the tubing • Always hang the drainage bad below the level of the bladder • The bag should never touch the floor to prevent accidental contamination during emptying • Keep drainage system patent Micturition: occurs when the brain gives the bladder permission to empty, the bladder contracts, the urinary sphincter relaxes, and urine leaves the body through the urethra *The glomerulus filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes; when proteinuria or hematuria is found, glomerular injury is suspected Review Questions: 1. A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.) 1. Ask the patient about any allergies and reactions. 2. Instruct the patient that a full bladder is required for the test. 3. Instruct the patient to save all urine in a special container. 4. Ensure that informed consent has been obtained. 5. Explain that the test includes instrumentation of the urinary tract. 2. When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider? 1. Pale yellow urine 2. Slightly cloudy urine 3. Light pink urine 4. Dark amber urine 3. What is a critical step when inserting an indwelling catheter into a male patient? 1. Slowly inflate the catheter balloon with sterile saline. 2. Secure the catheter drainage tubing to the bed sheets. 3. Advance the catheter to the bifurcation of the drainage and balloon ports. 4. Advance the catheter until urine flows, then insert inch more. 4. Which nursing intervention minimizes the risk for trauma and infection when applying an external/condom catheter? 1. Leaving a gap of 3 to 5 inches between the tip of the penis and drainage tube 2. Shaving the pubic area so hair does not adhere 3. Washing with soap and water before applying the condom-type catheter 4. Applying tape to the condom sheath to keep it securely in place 5. Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day? 1. Limit oral fluid intake to avoid possible urinary incontinence. 2. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding. 4. Instruct patient to stay in bed and use a urinal or bedpan. 6. A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention? 1. Increase the rate of the CBI 2. Assess the intake and output from system 3. Decrease the rate of the CBI 4. Assess vital signs 7. 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? 1. Recommend that she be evaluated for an overactive bladder (OAB) medication 2. Start a scheduled toileting program 3. Recommend that she be evaluated for an indwelling catheter 4. Start a bladder-retraining program 8. What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.) 1. Keep the bowels regular. 2. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear. 4. Cleanse the perineum from front to back. 5. Practice pelvic muscle exercise (Kegel) daily. 9. Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately? 1. Do you leak urine when you cough or sneeze? 2. Do you need help getting to the toilet? 3. Do you dribble urine constantly? 4. Does it burn when you pass your urine? 10. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order. 1. Insert and advance catheter. 5 2. Lubricate catheter. 3 3. Inflate catheter balloon. 7 4. Cleanse urethral meatus with antiseptic solution. 4 5. Drape patient with the sterile square and fenestrated drapes. 1 6. When urine appears, advance another 2.5 to 5 cm. 6 7. Prepare sterile field and supplies. 2 8. Gently pull catheter until resistance is felt. 8 9. Attach drainage tubing. 9 11. The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing intervention? 1. Implement the “as-needed” order to irrigate the catheter 2. Assess the catheter and drainage tubing for obvious occlusion 3. Notify the health care provider immediately 4. Assess the vital signs and intake and output record 12. Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.) 1. Attach a 3-mL syringe to the inflation port 2. Allow the balloon to drain into the syringe by gravity 3. Initiate a voiding record/bladder diary 4. Pull the catheter quickly 5. Clamp the catheter before removal 13. What best describes measurement of postvoid residual (PVR)? 1. Bladder scan the patient immediately after voiding. 2. Catheterize the patient 30 minutes after voiding. 3. Bladder scan the patient when he or she reports a strong urge to void. 4. Catheterize the patient with a 16 Fr/10 mL catheter. 1147 14. Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? 1. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution 2. Hanging the urinary drainage bag below the level of the bladder 3. Emptying the urinary drainage bag daily 4. Irrigating the urinary catheter with sterile water 15. There is no urine when a catheter is inserted 3 inches into a female's urethra. What should the nurse do next? 1. Remove the catheter and start all over with a new kit and catheter 2. Leave the catheter there and start over with a new catheter 3. Pull the catheter back and reinsert at a different angle 4. Ask the patient to bear down and insert the catheter further Test Bank Questions: 1. A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine? a. Kidney, urethra, bladder, ureters b. Kidney, ureters, bladder, urethra c. Bladder, kidney, ureters, urethra d. Bladder, kidney, urethra, ureters ANS: B The flow of urine follows these structures: kidney, ureters, bladder, and urethra. 2. A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up? a. Protein level of 2 mg/100 mL b. Urine output of 80 mL/hr c. Specific gravity of 1.036 d. pH of 6.4 ANS: C Dehydration, reduced renal blood flow, and increase in antidiuretic hormone secretion elevate specific gravity. Normal specific gravity is 1.0053 to 1.030. An output of 30 mL/hr or less for 2 or more hours would be cause for concern; 80 mL/hr is normal. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease. 3. A patient is experiencing oliguria. Which action should the nurse perform first? a. Assess for bladder distention. b. Request an order for diuretics. c. Increase the patient’s intravenous fluid rate. d. Encourage the patient to drink caffeinated beverages. ANS: A Oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action. 4. A patient requests the nurse’s help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient’s inability to void? a. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output. ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. Anxiety can impact bladder emptying due to inadequate relaxation of the pelvic floor muscles and urinary sphincter. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological (does not recognize signals or not drinking enough fluids) or psychological (lonely) condition exists. 5. The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action? a. The patient may void uncontrollably during the procedure. b. Local trauma sometimes promotes excessive urine incontinence. c. Anesthetics can decrease bladder contractility and cause urinary retention. d. The patient will not interrupt the procedure by asking to go to the bathroom. ANS: C Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness, causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow, requiring temporary use of an indwelling urinary catheter. The patient is more likely to retain urine rather than experience uncontrollable voiding. 6. The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria? a. Blood in the urine b. Burning upon urination c. Immediate, strong desire to void d. Awakes from sleep due to urge to void ANS: B Dysuria is burning or pain with urination. Hematuria is blood in the urine. Urgency is an immediate and strong desire to void that is not easily deferred. Nocturia is awakening form sleep due to urge to void. 7. An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient’s plan of care? a. Functional urinary incontinence b. Urge urinary incontinence c. Impaired skin integrity d. Urinary retention ANS: B Urge urinary incontinence is the leakage of urine associated with a strong urge to void. Patients leak urine on the way to or at the toilet and rush or hurry to the toilet. Urinary retention is the inability to empty the bladder. Functional urinary incontinence is incontinence due to causes outside the urinary tract, such as mobility or cognitive impairments. While Impaired skin integrity can occur, it is not the priority at this time, and there is no data to support this diagnosis. 8. A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Limit fluid and caffeine intake before bed. b. Leave the bathroom light on to illuminate a pathway. c. Practice Kegel exercises to strengthen bladder muscles. d. Clear the path to the bathroom of all obstacles before bedtime. ANS: A Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. To prevent nocturia, suggest that the patient avoid drinking fluids 2 hours before bedtime. Clearing a path to the bathroom, illuminating the path, or shortening the distance to the bathroom may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing stress incontinence. 9. A nurse is caring for a male patient with urinary retention. Which action should the nurse take first? a. Limit fluid intake. b. Insert a urinary catheter. c. Assist to a standing position. d. Ask for a diuretic medication. ANS: C In some patients just helping them to a normal position to void prompts voiding. A urinary catheter would relieve urinary retention, but it is not the first measure; other nursing interventions should be tried before catheterization. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention and is usually not recommended unless the retention is severe. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. 10. Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most appropriate? a. “Does your urinary problem interfere with any activities?” b. “Do you lose urine when you cough or sneeze?” c. “When was the last time you voided?” d. “Are you experiencing a fever or chills?” ANS: C To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended; time of last void is most appropriate. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, interference with any activities, and losing urine during coughing or sneezing focus on specific pathological conditions. 11. A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel? a. Obtaining a midstream urine specimen b. Interpreting a bladder scan result c. Inserting a straight catheter d. Irrigating a catheter ANS: A The skill of collecting midstream (clean-voided) urine specimens can be delegated to nursing assistive personnel. The nurse must first determine the timing and frequency of the bladder scan measurement and interprets the measurements obtained. Inserting a straight or an indwelling catheter cannot be delegated. Catheter irrigation or instillation cannot be delegated to nursing assistive personnel. 12. While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, which finding will the nurse expect? a. An indwelling Foley catheter b. Reddened irritated skin on buttocks c. Tiny blood clots in the patient’s urine d. Foul-smelling discharge indicative of infection ANS: B Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection. 13. A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do? a. Throw the catheter way and begin again. b. Fill the balloon with the recommended sterile water. c. Remove the catheter, wipe with alcohol, and reinsert after lubrication. d. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter. ANS: D If no urine appears, the catheter may be in the vagina. If misplaced, leave the catheter in the vagina as a landmark to indicate where not to insert, and insert another sterile catheter. The catheter should be left in place until the new, sterile catheter is inserted. The balloon should not be filled since the catheter is in the vagina. The catheter must be sterile; using alcohol will not make the catheter sterile. 14. A patient asks about treatment for stress urinary incontinence. Which is the nurse’s best response? a. Perform pelvic floor exercises. b. Avoid voiding frequently. c. Drink cranberry juice. d. Wear an adult diaper. ANS: A Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient’s problem. Evidence has shown that patients with urgency, stress, and mixed urinary incontinence can eventually achieve continence when treated with pelvic floor muscle training. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail. 15. The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report? a. Dysuria b. Flank pain c. Frequency d. Fever ANS: C Cystitis is inflammation of the bladder; associated symptoms include hematuria, foul-smelling cloudy urine, and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection (bladder). Flank pain, fever, and chills are all signs of pyelonephritis (upper urinary tract). 16. Which assessment question should the nurse ask if stress incontinence is suspected? a. “Do you think your bladder feels distended?” b. “Do you empty your bladder completely when you void?” c. “Do you experience urine leakage when you cough or sneeze?” d. “Do your symptoms increase with consumption of alcohol or caffeine?” ANS: C Stress incontinence can be related to intraabdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of the bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence. 17. The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one? 1. Clean injection port. 2. Inject prescribed solution. 3. Twist needleless syringe into port. 4. Remove clamp and allow to drain. 5. Clamp catheter just below specimen port. 6. Draw up prescribed amount of sterile solution ordered. a. 3, 2, 6, 1, 5, 4 b. 5, 6, 1, 2, 3, 4 c. 1, 5, 6, 3, 2, 4 d. 6, 5, 1, 3, 2, 4 ANS: D The steps for irrigating with a needleless closed irrigation technique is as follows: Draw up in a syringe the prescribed amount of medication or sterile solution; clamp indwelling retention catheter just below specimen port; using circular motion, clean injection port with antiseptic swab; insert tip of needleless syringe using twisting motion into irrigation port; slowly and evenly inject fluid into catheter and bladder; and withdraw syringe, remove clamp, and allow solution to drain into drainage bag. 18. To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do? a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Drink fluids 5 minutes before collecting the urine specimen. d. Hold the labia apart while voiding into the specimen cup. ANS: D The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front to back). The initial stream flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 minutes before giving a specimen. 19. A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection? a. Casts b. Protein c. Crystals d. Bacteria ANS: D Bacteria in the urine along with other symptoms support a diagnosis of urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal disease. Protein indicates kidney function and damage to the glomerular membrane such as in glomerulonephritis. 20. The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect? a. Red color b. Orange color c. Dark amber color d. Intense yellow color ANS: B Some drugs change the color of urine (e.g., phenazopyridine—orange, riboflavin—intense yellow). Eating beets, rhubarb, and blackberries causes red urine. Dark amber urine is the result of high concentrations of bilirubin in patients with liver disease. 21. Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Reduced urine specific gravity b. Increased blood pressure c. Abnormal blood sugar d. Fever with chills ANS: D Fever and chills may be observed. The presence of white blood cells in urine indicates a urinary tract infection or inflammation. Overhydration, early renal disease, and inadequate antidiuretic hormone secretion reduce specific gravity. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine or a patient with diabetes. 22. A patient has severe flank pain. The urinalysis reveals presence of calcium phosphate crystals. The nurse will anticipate an order for which diagnostic test? a. Intravenous pyelogram b. Mid-stream urinalysis c. Bladder scan d. Cystoscopy ANS: A Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A mid-stream urinalysis is performed for a routine urinalysis or if an infection is suspected; a urinalysis was already performed, a mid-stream would not be obtained again. A cystoscopy is used to detect bladder tumors and obstruction of the bladder outlet and urethra. A bladder scan measures the amount of urine in the bladder. 23. A nurse is caring for a patient who just underwent an intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’s first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Monitor the patient for fever, rash, and difficulty breathing. d. Administer narcotic medications to the patient for pain. ANS: C Assess for delayed hypersensitivity to the contrast media. Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety. 24. Which statement by the patient about an upcoming contrast computed tomography (CT) scan indicates a need for further teaching? a. “I will follow the food and drink restrictions as directed before the test is scheduled.” b. “I will be anesthetized so that I lie perfectly still during the procedure.” c. “I will complete my bowel prep program the night before the scan.” d. “I will be drinking a lot of fluid after the test is over.” ANS: B Patients are not put under anesthesia for a CT scan; instead, the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct and require no further teaching. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT scan. Bowel cleansing is often performed before CT scan. Another area to address is food and fluid restriction up to 4 hours prior to the test. After the procedure, encourage fluids to promote dye excretion. 25. The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take? a. Measure bladder before the patient voids. b. Measure bladder within 10 minutes after the patient voids. c. Measure bladder with head of bed raised to 60 degrees. d. Measure bladder with head of bed raised to 90 degrees. ANS: B Measurement should be within 10 minutes of voiding. It is a postvoid so the measurement is after the patient voids and the urine volume is recorded. Patient is supine with head slightly elevated. 26. A nurse is watching a nursing assistive personnel (NAP) perform a postvoid bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up? a. Palpates the patient’s symphysis pubis b. Wipes scanner head with alcohol pad c. Applies a generous amount of gel d. Sets the scanner to female ANS: D The nurse will follow up if the NAP sets the scanner to female. Women who have had a hysterectomy should be designated as male. All the rest are correct and require no follow-up. The NAP should palpate the symphysis pubis, the scanner head should be cleaned with an alcohol pad, and a generous amount of gel should be applied. 27. A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient’s progress. b. Utilizing the power of suggestion by turning on the faucet and letting the water run. c. Obtaining an order for a Foley catheter. d. Administering diuretic medication. ANS: B To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition. 28. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. “Set your alarm clock to wake you every 2 hours, so you can get up to void.” b. “Line your bedding with plastic sheets to protect your mattress.” c. “Drink your nightly glass of milk earlier in the evening.” d. “Empty your bladder completely before going to bed.” ANS: C Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination but will not affect urine produced throughout the night from late-night fluid intake. 29. A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take? a. Hold the shaft of the penis at a 60-degree angle. b. Hold the shaft of the penis with the dominant hand. c. Cleanse the meatus 3 times with the same cotton ball from clean to dirty. d. Cleanse the meatus with circular strokes beginning at the meatus and working outward. ANS: D Using the uncontaminated dominant hand, cleanse the meatus with cotton balls/swab sticks, using circular strokes, beginning at the meatus and working outward in a spiral motion. Repeat 3 times using a clean cotton ball/swabstick each time. With the nondominant hand (now contaminated), retract the foreskin (if uncircumcised) and gently grasp the penis at the shaft just below the glans. Hold the shaft of the penis at a right angle to the body. 30. The nurse will anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection ANS: C A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women. 31. A nurse is evaluating a nursing assistive personnel’s (NAP) care for a patient with an indwelling catheter. Which action by the NAP will cause the nurse to intervene? a. Emptying the drainage bag when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient’s bed d. Securing the catheter tubing to the patient’s thigh ANS: C Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. A key intervention to prevent catheter-associated urinary tract infections is prevention of urine back flow from the tubing and bag into the bladder. All the rest are correct procedures and do not require follow-up. The drainage bag should be emptied when half full; an overfull drainage bag can create tension and pulling on the catheter, resulting in trauma to the urethra and/or urinary meatus and increasing risk for urinary tract infections. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient’s thigh places the patient at risk for tissue injury from catheter dislodgment. 32. A nurse is caring for a patient with a continent urinary reservoir. Which action will the nurse take? a. Teach the patient how to self-cath the pouch. b. Teach the patient how to perform Kegel exercises. c. Teach the patient how to change the collection pouch. d. Teach the patient how to void using the Valsalva technique. ANS: A In a continent urinary reservoir, the ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted through the stoma to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives. The second type of continent urinary diversion is called an orthotopic neobladder, which uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position as the bladder was before removal, allowing a patient to void through the urethra using a Valsalva technique. In a ureterostomy or ileal conduit the patient has no sensation or control over the continuous flow of urine through the ileal conduit, requiring the effluent (drainage) to be collected in a pouch. Kegel exercises are ineffective for a patient with a continent urinary reservoir. 33. The nurse is preparing to apply an external catheter. Which action will the nurse take? a. Allow 1 to 2 inches of space between the tip of the penis and the end of the catheter. b. Spiral wrap the penile shaft using adhesive tape to secure the catheter. c. Twist the catheter before applying drainage tubing to the end of the catheter. d. Shave the pubic area before applying the catheter. ANS: A When applying an external catheter, allow 2.5 to 5 cm (1 to 2 inches) of space between the tip of the penis and the end of the catheter. Spiral wrap the penile shaft with supplied elastic adhesive. The strip should not overlap. The elastic strip should be snug but not tight. NOTE: Never use adhesive tape. Connect drainage tubing to the end of the condom catheter. Be sure the condom is not twisted. Connect the catheter to a large-volume drainage bag or leg. Clip hair at the base of the penile shaft, as necessary. Do not shave the pubic area. 34. A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection? a. Maintaining a closed urinary drainage system b. Inserting the catheter using strict clean technique c. Disconnecting and replacing the catheter drainage bag once per shift d. Fully inflating the catheter’s balloon according to the manufacturer’s recommendation ANS: A A key intervention to prevent infection is maintaining a closed urinary drainage system. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgment and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection. 35. A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? a. Drapes the urinary drainage tubing with no dependent loops b. Washes the drainage tube toward the meatus with soap and water c. Places the urinary drainage bag gently on the floor below the patient d. Allows the spigot to touch the receptacle when emptying the drainage bag ANS: A Avoid dependent loops in urinary drainage tubing. Prevent the urinary drainage bag from touching or dragging on the floor. When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. Using a clean wash cloth, soap, and water, with your dominant hand wipe in a circular motion along the length of the catheter for about 10 cm (4 inches), starting at the meatus and moving away. 36. A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A patient who is dribbling small amounts on the way to the bathroom and has a diagnosis of urge incontinence b. A patient with reflex incontinence with elevated blood pressure and pulse rate c. A patient with an indwelling catheter that has stool on the catheter tubing d. A patient who has just voided and needs a postvoid residual test ANS: B The nurse should see the patient with reflex incontinence first. Patients with reflex incontinence are at risk for developing autonomic dysreflexia, a life-threatening condition that causes severe elevation of blood pressure and pulse rate and diaphoresis. This is a medical emergency requiring immediate intervention; notify the health care provider immediately. A patient with urge incontinence will dribble, and this is expected. While a patient with a catheter and stool on the tubing does need to be cleaned, it is not life threatening. The nurse has 10 minutes before checking on the patient who has a postvoid residual test. 37. To reduce patient discomfort during a closed intermittent catheter irrigation, what should the nurse do? a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of the irrigation solution at least 12 inches above the bladder. ANS: A To reduce discomfort use room temperature solution. Using cold solutions and instilling solutions too quickly can cause discomfort. During an irrigation, the solution does not sit in the bladder; it is allowed to drain. A container is not raised about the bladder 12 inches when performing a closed intermittent catheter irrigation. 38. Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective? a. Output that is smaller than the amount instilled b. Blood clots or sediment in the drainage bag c. Bright red urine turns pink in the tubing d. Bladder distention with tenderness ANS: C If urine is bright red or has clots, increase irrigation rate until drainage appears pink, indicating successful irrigation. Expect more output than fluid instilled because of urine production. If output is smaller than the amount instilled, suspect that the tube may be clogged. The presence of blood clots indicates the patient is still bleeding, while sediment could mean an infection or bleeding. The bladder should not be distended or tender; the irrigant may not be flowing freely if these occur, or the tube may be kinked or blocked. DIF:Apply (application)REF:1144 39. The nurse anticipates a suprapubic catheter for which patient? a. A patient with recent prostatectomy b. A patient with a urethral stricture c. A patient with an appendectomy d. A patient with menopause ANS: B A patient with a urethral stricture is most likely to have a suprapubic catheter. Suprapubic catheters are placed when there is blockage of the urethra (e.g., enlarged prostate, urethral stricture, after urological surgery). A patient with a recent prostatectomy indicates the enlarged prostate was removed and would not need a suprapubic catheter; however, continuous bladder irrigation may be needed. Appendectomies and menopause do not require a suprapubic catheter. 1. Which nursing actions will the nurse implement when collecting a urine specimen from a patient? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Allowing the patient adequate time and privacy to void d. Wearing gown, gloves, and mask for all specimen handling e. Transporting specimens to the laboratory in a timely manner f. Collecting the specimen from the drainage bag of an indwelling catheter ANS: B, C, E All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Urine cultures can take up to 48 to 72 hours to develop. Only gloves are necessary to handle a urine specimen. Gown and mask are not needed unless otherwise indicated. Never collect the specimen from the drainage bag of a catheter; obtain the sample from the special sampling port. 2. The nurse is obtaining a 24-hour urine specimen collection from the patient. Which actions should the nurse take? (Select all that apply.) a. Keeping the urine collection container on ice when indicated b. Withholding all patient medications for the day c. Irrigating the sample as needed with sterile solution d. Testing the urine sample with a reagent strip by dipping it in the urine e. Asking the patient to void and discarding that urine to start the collection ANS: A, E When obtaining a 24-hour urine specimen, it is important to keep the urine in cool conditions, depending upon the test. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution. A 24-hour urine specimen is not tested with a reagent strip. 3. Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply.) a. Increasing fluid intake b. Dribbling of urine c. Voiding in small amounts d. Voiding within 6 hours of catheter removal e. Burning with the first couple of times voiding ANS: B, C Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts can indicate inadequate bladder emptying requiring intervention. All the rest are normal and do not require follow-up. The patient should increase intake. The first few times a patient voids after catheter removal may be accompanied by some discomfort, but continued complaints of painful urination indicate possible infection. Patient should void 6 to 8 hours after catheter removal. 4. A nurse administers an antimuscarinic to a patient. Which findings indicate the patient is having therapeutic effects from this medication? (Select all that apply.) a. Decrease in dysuria b. Decrease in urgency c. Decrease in frequency d. Decrease in prostate size e. Decrease in bladder infection ANS: B, C When newly started on an antimuscarinic, you should monitor the patient for effectiveness, watching for a decrease in symptoms such as urgency, frequency, and urgency urinary incontinence episodes. Patients with painful urination are sometimes prescribed urinary analgesics that act on the urethral and bladder mucosa (e.g., phenazopyridine). Antibiotics are used to treat bladder infections. Agents that shrink the prostate include finasteride and dutasteride. 5. The nurse is using different toileting schedules. Which principles will the nurse keep in mind when planning care? (Select all that apply.) a. Habit training uses a bladder diary. b. Timed voiding is based upon the patient’s urge to void. c. Prompted voiding includes asking patients if they are wet or dry. d. Elevation of feet in patients with edema can decrease nighttime voiding. e. Bladder retraining teaches patients to follow the urge to void as quickly as possible. ANS: A, C Habit training is a toileting schedule based upon the patient’s usual voiding pattern. Using a bladder diary, the usual times a patient voids are identified. It is at these times that the patient is then toileted. Prompted voiding is a program of toileting designed for patients with mild or moderately cognitive impairment. Patients are toileted based upon their usual voiding pattern. Caregivers ask the patient if they are wet or dry, give positive feedback for dryness, prompt the patient to toilet, and reward the patient for desired behavior. Timed voiding or scheduled toileting is toileting based upon a fixed schedule, not the patient’s urge to void. The schedule maybe set by a time interval, every 2 to 3 hours or at times of day such as before and after meals. In bladder retraining, patients are taught to inhibit the urge to void by taking slow and deep breaths to relax, perform 5 to 6 quick strong pelvic muscle exercises (flicks) in quick succession followed by distracting attention from bladder sensations. When the urge to void becomes less severe or subsides, only then should the patient start the trip to the bathroom. Encourage patients with edema to elevate the feet for a minimum of a few hours in the afternoon to help diminish nighttime voiding frequency; while this is helpful, it is not a toileting schedule. Chapter 47: Bowel Elimination • Small intestine- transport; more liquid stool • Large intestine/colon- solid and more formed stool Bowel Assessment: • Usual elimination pattern • Description of stool- color, consistency, etc • Changes in appetite • Diet hx- diet log or history • Intake • Hx of surgeries • Medication hx Physical Assessment of the bowels: • Mouth- inspect; wear gloves • Abdomen- observe for contour, shape, symmetry; look at four quadrants of abdomen • Auscultate the abdomen to assess bowel sounds in each quadrant • Palpate Factors that influence bowel elimination: • Age • Diet • Fluid intake • Physical activity • Psychological factors • Pregnancy- more constipated • Surgery/anesthesia • medications Common Bowel Elimination Problems: • constipation- decrease production or mobility • impaction- happens only in rectal area bc of build up of stool • diarrhea • incontinence • flatulence • hemorrhoids Enemas: • cleansing (used in pre-op) • tap water- stimulates evacuation; never repeated due to potential water toxicity • normal saline- safest due to equal osmotic pressure, volume stimulates peristalsis • hypertonic solutions- low volume, good for clients that cannot tolerate high-volume enemas o fleet- commercially prepared hypertonic enema • soapsuds- pure castile soap in tap water or normal saline; acts as an irritant to promote peristalsis • oil retention- lubricates the rectum and colon for easier passage of stool • others- catminative and kayexalate Bowel Diversions: • temporary of permanent artificial opening in the abdominal wall o stoma- should be dark pink or beefy red; if its light pink, it’s not being oxygenated properly • surgical opening in the ileum or colon o ileostomy (small intestine- liquid stool) or colonoscopy (large intestine- solid stool) • the standard bowel diversion creates a stoma Care of Ostomies: • Assessing the ostomy- size and color; should be beefy red in color; pale or black mean impaired blood flow • An ostomy requires a pouch to collect fecal material- one or two piece device • Nutrition- fluid intake; fiber • Psychological considerations- body image; self esteem; sexuality Diagnostic: • Laboratory test- fecal occult blood testing • Diagnostic examinations- direct visualization (endoscopy; colonoscopy) and indirect visualization (x-ray with contrast, US abdomen, CT scan abdomen, MRI) *Fluid and electrolyte imbalance are the most common complication after an ILEOSTOMY. Patient requires monitoring of I and Os because fat malabsorption and folate deficiency are complications that can occur later *A client with a new colostomy created 2 days ago is beginning to pass malodorous flatus from the stoma. The nurse’s initial action should be to document the assessment because patient is having resumes function which is a normal finding *The nurse should advise a patient with constipation to eat fresh fruit and whole wheat toast because they are high in fiber which promotes elimination *When a nurse is caring for a patient with diarrhea, they should asses hypotension (bc of fluid loss), fever (bc they might have something viral or bacterial or dehydration), and poor skin turgor (bc that can be the result of dehydration) *While the nurse is administering an enema, the patient reports cramping. The nurse should lower the enema fluid container because it will slow the rate to relieve discomfort Peristalsis: is a contraction that propels food through the length of the GI tract Stomach Functions: 1. Stores swallowed food 2. Mixes food with digestive juices into chyme 3. Regulates the emptying of its contents into the small intestine Colon Function: 1. Absorption 2. Secretion 3. Elimination Hemorrhoids- results from pressure on the veins during straining Review Questions MULTIPLE CHOICE 1. The nurse is teaching a health class about the gastrointestinal tract. The nurse will explain that which portion of the digestive tract absorbs most of the nutrients? a. Ileum b. Cecum c. Stomach d. Duodenum ANS: D The duodenum and jejunum absorb most nutrients and electrolytes in the small intestine. The ileum absorbs certain vitamins, iron, and bile salts. Food is broken down in the stomach. The cecum is the beginning of the large intestine. 2. The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present? a. Sigmoid b. Transverse c. Ascending d. Descending ANS: C The path of digestion goes from the ascending, across the transverse, to the descending and finally passing into the sigmoid; therefore, the least formed stool (very liquid) would be in the ascending. 3. A nurse is teaching a patient about the large intestine in elimination. In which order will the nurse list the structures, starting with the first portion? a. Cecum, ascending, transverse, descending, sigmoid, and rectum b. Ascending, transverse, descending, sigmoid, rectum, and cecum c. Cecum, sigmoid, ascending, transverse, descending, and rectum d. Ascending, transverse, descending, rectum, sigmoid, and cecum ANS: A The large intestine is divided into the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. The large intestine is the primary organ of bowel elimination. 4. The nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel (NAP)? a. Performing the first postoperative pouch change b. Maintaining a nasogastric tube c. Administering an enema d. Digitally removing stool ANS: C The skill of administering an enema can be delegated to an NAP. The skill of inserting and maintaining a nasogastric (NG) tube cannot be delegated to an NAP. The nurse should do the first postoperative pouch change. Digitally removing stool cannot be delegated to nursing assistive personnel. 5. A nurse is assisting a patient in making dietary choices that promote healthy bowel elimination. Which menu option should the nurse recommend? a. Broccoli and cheese soup with potato bread b. Turkey and mashed potatoes with brown gravy c. Grape and walnut chicken salad sandwich on whole wheat bread d. Dinner salad topped with hard-boiled eggs, cheese, and fat-free dressing ANS: C Grapes and whole wheat bread are high fiber and should be chosen. Cheese, eggs, potato bread, and mashed potatoes do not contain as much fiber as whole wheat bread. A healthy diet for the bowel should include foods high in bulk-forming fiber. Whole grains, fresh fruit, and fresh vegetables are excellent sources. Foods without much fiber and with high levels of fat can slow down peristalsis, causing constipation. 6. A patient is using laxatives three times daily to lose weight. After stopping laxative use, the patient has difficulty with constipation and wonders if laxatives should be taken again. Which information will the nurse share with the patient? a. Long-term laxative use causes the bowel to become less responsive to stimuli, and constipation may occur. b. Laxatives can cause trauma to the intestinal lining and scarring may result, leading to decreased peristalsis. c. Long-term use of emollient laxatives is effective for treatment of chronic constipation and may be useful in certain situations. d. Laxatives cause the body to become malnourished, so when the patient begins eating again, the body absorbs all of the food, and no waste products are produced. ANS: A Teach patients about the potential harmful effects of overuse of laxatives, such as impaired bowel motility and decreased response to sensory stimulus. Make sure the patient understands that laxatives are not to be used long term for maintenance of bowel function. Increasing fluid and fiber intake can help with this problem. Laxatives do not cause scarring. Even if malnourished, the body will produce waste if any substance is consumed. 7. A patient with a hip fracture is having difficulty defecating into a bedpan while lying in bed. Which action by the nurse will assist the patient in having a successful bowel movement? a. Preparing to administer a barium enema b. Withholding narcotic pain medication c. Administering laxatives to the patient d. Raising the head of the bed ANS: D Lying in bed is an unnatural position; raising the head of the bed assists the patient into a more normal position that allows proper contraction of muscles for elimination. Laxatives would not give the patient control over bowel movements. A barium enema is a diagnostic test, not an intervention to promote defecation. Pain relief measures should be given; however, preventative action should be taken to prevent constipation. 8. Which patient is most at risk for increased peristalsis? a. A 5-year-old child who ignores the urge to defecate owing to embarrassment b. A 21-year-old female with three final examinations on the same day c. A 40-year-old female with major depressive disorder d. An 80-year-old male in an assisted-living environment ANS: B Stress can stimulate digestion and increase peristalsis, resulting in diarrhea; three finals on the same day is stressful. Ignoring the urge to defecate, depression, and age-related changes of the older adult (80-year-old man) are causes of constipation, which is from slowed peristalsis. 9. A patient expresses concerns over having black stool. The fecal occult test is negative. Which response by the nurse is most appropriate? a. “This is probably a false negative; we should rerun the test.” b. “You should schedule a colonoscopy as soon as possible.” c. “Are you under a lot of stress?” d. “Do you take iron supplements?” ANS: D Certain medications and supplements, such as iron, can alter the color of stool (black or tarry). Since the fecal occult test is negative, bleeding is not occurring. The fecal occult test takes three separate samples over a period of time and is a fairly reliable test. A colonoscopy is health prevention screening that should be done every 5 to 10 years; it is not the nurse’s initial priority. Stress alters GI motility and stool consistency, not color. 10. Which patient will the nurse assess most closely for an ileus? a. A patient with a fecal impaction b. A patient with chronic cathartic abuse c. A patient with surgery for bowel disease and anesthesia d. A patient with suppression of hydrochloric acid from medication ANS: C Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. Anesthesia can also cause cessation of peristalsis. This condition, called an ileus, usually lasts about 24 to 48 hours. Fecal impaction, cathartic abuse, and medication to suppress hydrochloric acid will have bowel sounds, but they may be hypoactive or hyperactive. 11. A patient has a fecal impaction. Which portion of the colon will the nurse assess? a. Descending b. Transverse c. Ascending d. Rectum ANS: D A fecal impaction is a collection of hardened feces wedged in the rectum that cannot be expelled. It results from unrelieved constipation. Feces at this point in the colon contain the least amount of moisture. Feces found in the ascending, transverse, and descending colon still consist mostly of liquid and do not form a hardened mass. 12. The nurse is managing bowel training for a patient. To which patient is the nurse most likely providing care? a. A 25-year-old patient with diarrhea b. A 30-year-old patient with Clostridium difficile c. A 40-year-old patient with an ileostomy d. A 70-year-old patient with stool incontinence ANS: D The patient with chronic constipation or fecal incontinence secondary to cognitive impairment may benefit from bowel training, also called habit training. An ileostomy, diarrhea, and C. difficile all relate to uncontrollable bowel movements, for which no method can be used to set up a schedule of elimination. 13. Which nursing intervention is most effective in promoting normal defecation for a patient who has muscle weakness in the legs? a. Administer a soapsuds enema every 2 hours. b. Use a mobility device to place the patient on a bedside commode. c. Give the patient a pillow to brace against the abdomen while bearing down. d. Elevate the head of the bed 20 degrees 60 minutes after breakfast while on bedpan. ANS: B The best way to promote normal defecation is to assist the patient into a posture that is as normal as possible for defecation. Using a mobility device promotes nurse and patient safety. Elevating the head of the bed is appropriate but is not the most effective; closer to 30 to 45 degrees is the proper position for the patient on a bedpan, and the patient is not on bed rest so a bedside commode is the best choice. Giving the patient a pillow may reduce discomfort, but this is not the best way to promote defecation. A soapsuds enema is indicated for a patient who needs assistance to stimulate peristalsis. It promotes non-natural defecation. 14. The nurse is devising a plan of care for a patient with the nursing diagnosis of Constipation related to opioid use. Which outcome will the nurse evaluate as successful for the patient to establish normal defecation? a. The patient reports eliminating a soft, formed stool. b. The patient has quit taking opioid pain medication. c. The patient’s lower left quadrant is tender to the touch. d. The nurse hears bowel sounds in all four quadrants. ANS: A The nurse’s goal is for the patient to take opioid medication and to have normal bowel elimination. Normal stools are soft and formed. Ceasing pain medication is not a desired outcome for the patient. Tenderness in the left lower quadrant indicates constipation and does not indicate success. Bowel sounds indicate that the bowels are moving; however, they are not an indication of defecation. 15. The nurse is emptying an ileostomy pouch for a patient. Which assessment finding will the nurse report immediately? a. Liquid consistency of stool b. Presence of blood in the stool c. Malodorous stool d. Continuous output from the stoma ANS: B Blood in the stool indicates a problem, and the health care provider should be notified. All other options are expected findings for an ileostomy. The stool should be liquid, there should be an odor, and the output should be continuous. 16. The nurse will anticipate which diagnostic examination for a patient with black tarry stools? a. Ultrasound b. Barium enema c. Endoscopy d. Anorectal manometry ANS: C Black tarry stools are an indication of bleeding in the GI tract; endoscopy would allow visualization of the bleeding. No other option (ultrasound, barium enema, and anorectal manometry) would allow GI visualization. 17. The nurse has attempted to administer a tap water enema for a patient with fecal impaction with no success. The fecal mass is too large for the patient to pass voluntarily. Which is the next priority nursing action? a. Preparing the patient for a second tap water enema b. Obtaining an order for digital removal of stool c. Positioning the patient on the left side d. Inserting a rectal tube ANS: B When enemas are not successful, digital removal of the stool may be necessary to break up pieces of the stool or to stimulate the anus to defecate. Tap water enemas should not be repeated because of risk of fluid imbalance. Positioning the patient on the left side does not promote defecation. A rectal tube is indicated for a patient with liquid stool incontinence or flatus but would not be applicable or effective for this patient. 18. A nurse is checking orders. Which order should the nurse question? a. A normal saline enema to be repeated every 4 hours until stool is produced b. A hypertonic solution enema for a patient with fluid volume excess c. A Kayexalate enema for a patient with severe hypokalemia d. An oil retention enema for a patient with constipation ANS: C Kayexalate binds to and helps excrete potassium, so it would be contraindicated in patients who are hypokalemic (have low potassium). Normal saline enemas can be repeated without risk of fluid or electrolyte imbalance. Hypertonic solutions are intended for patients who cannot handle large fluid volume and are contraindicated for dehydrated patients. Oil retention enemas lubricate the feces in the rectum and colon and are used for constipation. 19. The nurse is performing a fecal occult blood test. Which action should the nurse take? a. Test the quality control section before testing the stool specimens. b. Apply liberal amounts of stool to the guaiac paper. c. Report a positive finding to the provider. d. Don sterile disposable gloves. ANS: C Abnormal findings such as a positive test (turns blue) should be reported to the provider. A fecal occult blood test is a clean procedure; sterile gloves are not needed. A thin specimen smear is all that is required. The quality control section should be developed after it is determined whether the sample is positive or negative. 20. A nurse is preparing a patient for a magnetic resonance imaging (MRI) scan. Which nursing action is most important? a. Ensuring that the patient does not eat or drink 2 hours before the examination. b. Administering a colon cleansing product 6 hours before the examination. c. Obtaining an order for a pain medication before the test is performed. d. Removing all of the patient’s metallic jewelry. ANS: D No jewelry or metal products should be in the same room as an MRI machine because of the high- power magnet used in the machine. The patient needs to be NPO 4 to 6 hours before the examination. Colon cleansing products are not necessary for MRIs. Pain medication is not needed before the examination is performed. 21. A patient with a fecal impaction has an order to remove stool digitally. In which order will the nurse perform the steps, starting with the first one? 1. Obtain baseline vital signs. 2. Apply clean gloves and lubricate. 3. Insert index finger into the rectum. 4. Identify patient using two identifiers. 5. Place patient on left side in Sims’ position. 6. Massage around the feces and work down to remove. a. 4, 1, 5, 2, 3, 6 b. 1, 4, 2, 5, 3, 6 c. 4, 1, 2, 5, 3, 6 d. 1, 4, 5, 2, 3, 6 ANS: A The steps for removing a fecal impaction are as follows: identify patient using two identifiers; obtain baseline vital signs; place on left side in Sims’ position; apply clean gloves and lubricate; insert index finger into the rectum; and gently loosen the fecal mass by massaging around it and work the feces downward toward the end of the rectum. 22. Before administering a cleansing enema to an 80-year-old patient, the patient says “I don’t think I will be able to hold the enema.” Which is the next priority nursing action? a. Rolling the patient into right-lying Sims’ position b. Positioning the patient in the dorsal recumbent position on a bedpan c. Inserting a rectal plug to contain the enema solution after administering d. Assisting the patient to the bedside commode and administering the enema ANS: B If you suspect the patient of having poor sphincter control, position on bedpan in a comfortable dorsal recumbent position. Patients with poor sphincter control are unable to retain all of the enema solution. Administering an enema with the patient sitting on the toilet is unsafe because it is impossible to safely guide the tubing into the rectum, and it will be difficult for the patient to retain the fluid as he or she is in the position used for emptying the bowel. Rolling the patient into right-lying Sims’ position will not help the patient retain the enema. Use of a rectal plug to contain the solution is inappropriate and unsafe. 23. A nurse is providing care to a group of patients. Which patient will the nurse see first? a. A child about to receive a normal saline enema b. A teenager about to receive loperamide for diarrhea c. An older patient with glaucoma about to receive an enema d. A middle-aged patient with myocardial infarction about to receive docusate sodium ANS: C An enema is contradicted in a patient with glaucoma; this patient should be seen first. All the rest are expected. A child can receive normal saline enemas since they are isotonic. Loperamide, an antidiarrheal, is given for diarrhea. Docusate sodium is given to soften stool for patients with myocardial infarction to prevent straining. 24. A patient is diagnosed with a bowel obstruction. Which type of tube is the best for the nurse to obtain for gastric decompression? a. Salem sump b. Small bore c. Levin d. 8 Fr ANS: A The Salem sump tube is preferable for stomach decompression. The Salem sump tube has two lumina: one for removal of gastric contents and one to provide an air vent. When the main lumen of the sump tube is connected to suction, the air vent permits free, continuous drainage of secretions. While the Levin tube can be used for decompression, it is only a single-lumen tube with holes near the tip. Large-bore tubes, 12 Fr and above, are usually used for gastric decompression or removal of gastric secretions. Fine- or small-bore tubes are frequently used for medication administration and enteral feedings. 25. A patient had an ileostomy surgically placed 2 days ago. Which diet will the nurse recommend to the patient to ease the transition of the new ostomy? a. Eggs over easy, whole wheat toast, and orange juice with pulp b. Chicken fried rice with fresh pineapple and iced tea c. Turkey meatloaf with white rice and apple juice d. Fish sticks with sweet corn and soda ANS: C During the first few days after ostomy placement, the patient should consume easy-to-digest soft foods such as poultry, rice, and noodles. Fried foods can irritate digestion. Foods high in fiber will be useful later in the recovery process but can cause food blockage if the GI tract is not accustomed to digesting with an ileostomy. Foods with indigestible fiber such as sweet corn, popcorn, raw mushrooms, fresh pineapple, and Chinese cabbage could cause this problem. 26. A nurse is pouching an ostomy on a patient with an ileostomy. Which action by the nurse is most appropriate? a. Changing the skin barrier portion of the ostomy pouch daily b. Emptying the pouch if it is more than one-third to one-half full c. Thoroughly cleansing the skin around the stoma with soap and water to remove excess stool and adhesive d. Measuring the correct size for the barrier device while leaving a 1/2-inch space around the stoma ANS: B Pouches must be emptied when they are one-third to one-half full because the weight of the pouch may disrupt the seal of the adhesive on the skin. The barrier device should be changed every 3 to 7 days unless it is leaking or is no longer effective. Peristomal skin should be gently cleansed; vigorous rubbing can cause further irritation or skin breakdown. Avoid soap. It leaves a residue on skin, which may irritate the skin. The pouch opening should fit around the stoma and cover the peristomal skin to prevent contact with the effluent. Excess space, like 1/2 inch, allows fecal matter to have prolonged exposure to skin, resulting in skin breakdown. 27. The nurse will irrigate a patient’s nasogastric (NG) tube. Which action should the nurse take? a. Instill solution into pigtail slowly. b. Check placement after instillation of solution. c. Immediately aspirate after instilling fluid. d. Prepare 60 mL of tap water into Asepto syringe. ANS: C After instilling saline, immediately aspirate or pull back slowly on syringe to withdraw fluid. Do not introduce saline through blue “pigtail” air vent of Salem sump tube. Checking placement before instillation of normal saline prevents accidental entrance of irrigating solution into lungs. Draw up 30 mL of normal saline into Asepto syringe to minimize loss of electrolytes from stomach fluids. 28. The nurse administers a cathartic to a patient. Which finding helps the nurse determine that the cathartic has a therapeutic effect? a. Reports decreased diarrhea. b. Experiences pain relief. c. Has a bowel movement. d. Passes flatulence. ANS: C A cathartic is a laxative that stimulates a bowel movement. It would be effective if the patient experiences a bowel movement. The other options are not outcomes of administration of a cathartic. An antidiarrheal will provide relief from diarrhea. Pain medications will provide pain relief. Carminative enemas provide relief from gaseous distention (flatulence). 29. An older adult’s perineal skin is dry and thin with mild excoriation. When providing hygiene care after episodes of diarrhea, what should the nurse do? a. Thoroughly scrub the skin with a washcloth and hypoallergenic soap. b. Tape an occlusive moisture barrier pad to the patient’s skin. c. Apply a skin protective ointment after perineal care. d. Massage the skin with light kneading pressure. ANS: C Cleansing with a no-rinse cleanser and application of a barrier ointment should be done after each episode of diarrhea. Tape and occlusive dressings can damage skin. Excessive pressure and massage are inappropriate and may cause skin breakdown. 30. Which action will the nurse take to reduce the risk of excoriation to the mucosal lining of the patient’s nose from a nasogastric tube? a. Instill Xylocaine into the nares once a shift. b. Tape tube securely with light pressure on nare. c. Lubricate the nares with water-soluble lubricant. d. Apply a small ice bag to the nose for 5 minutes every 4 hours. ANS: C The tube constantly irritates the nasal mucosa, increasing the risk of excoriation. Frequent lubrication with a water-soluble lubricant decreases the likelihood of excoriation and is less toxic than oil-based if aspirated. Xylocaine is used to treat sore throat, not nasal mucosal excoriation. While the tape should be secure, pressure will increase excoriation. Ice is not applied to the nose. 31. A nurse is providing discharge teaching for a patient who is going home with a guaiac test. Which statement by the patient indicates the need for further education? a. “If I get a blue color that means the test is negative.” b. “I should not get any urine on the stool I am testing.” c. “If I eat red meat before my test, it could give me false results.” d. “I should check with my doctor to stop taking aspirin before the test.” ANS: A A blue color indicates a positive guaiac, or presence of fecal occult blood; the patient needs more teaching to correct this misconception. Proper patient education is important for viable results. Be sure specimen is free of toilet paper and not contaminated with urine. The patient needs to avoid certain foods, like red meat, to rule out a false positive. While the health care provider should be consulted before asking a patient to stop any medication, if there are no contraindications, the patient should be instructed to stop taking aspirin, ibuprofen, naproxen or other nonsteroidal antiinflammatory drugs for 7 days because these could cause a false-positive test result. 32. A nurse is preparing to lavage a patient in the emergency department for an overdose. Which tube should the nurse obtain? a. Ewald b. Dobhoff c. Miller-Abbott d. Sengstaken-Blakemore ANS: A Lavage is irrigation of the stomach in cases of active bleeding, poisoning, or gastric dilation. The types of tubes include Levin, Ewald, and Salem sump. Sengstaken-Blakemore is used for compression by internal application of pressure by means of inflated balloon to prevent internal esophageal or GI hemorrhage. Dobhoff is used for enteral feeding. Miller-Abbott is used for gastric decompression. 33. The nurse is caring for a patient with Clostridium difficile. Which nursing actions will have the greatest impact in preventing the spread of the bacteria? a. Appropriate disposal of contaminated items in biohazard bags b. Monthly in-services about contact precautions c. Mandatory cultures on all patients d. Proper hand hygiene techniques ANS: D Proper hand hygiene is the best way to prevent the spread of bacteria. Soap and water are mandatory. Monthly in-services place emphasis on education, not on action. Biohazard bags are appropriate but cannot be used on every item that C. difficile comes in contact with, such as a human. Mandatory cultures are expensive and unnecessary and would not prevent the spread of bacteria. 34. A nurse is performing an assessment on a patient who has not had a bowel movement in 3 days. The nurse will expect which other assessment finding? a. Hypoactive bowel sounds b. Increased fluid intake c. Soft tender abdomen d. Jaundice in sclera ANS: A Three or more days with no bowel movement indicates hypomotility of the GI tract. Assessment findings would include hypoactive bowel sounds, a firm distended abdomen, and pain or discomfort upon palpation. Increased fluid intake would help the problem; a decreased intake can lead to constipation. Jaundice does not occur with constipation but can occur with liver disease. 35. A nurse is caring for a patient who has had diarrhea for the past week. Which additional assessment finding will the nurse expect? a. Distended abdomen b. Decreased skin turgor c. Increased energy levels d. Elevated blood pressure ANS: B Chronic diarrhea can result in dehydration. Patients with chronic diarrhea are dehydrated with decreased skin turgor and blood pressure. Diarrhea also causes loss of electrolytes, nutrients, and fluid, which decreases energy levels. A distended abdomen could indicate constipation. 36. The nurse is caring for a patient who had a colostomy placed yesterday. The nurse should report which assessment finding immediately? a. Stoma is protruding from the abdomen. b. Stoma is flush with the skin. c. Stoma is purple. d. Stoma is moist. ANS: C A purple stoma may indicate strangulation/necrosis or poor circulation to the stoma and may require surgical intervention. A stoma should be reddish-pink and moist in appearance. It can be flush with the skin, or it can protrude. 37. A patient is receiving a neomycin solution enema. Which primary goal is the nurse trying to achieve? a. Prevent gaseous distention b. Prevent constipation c. Prevent colon infection d. Prevent lower bowel inflammation ANS: C A medicated enema is a neomycin solution, i.e., an antibiotic used to reduce bacteria in the colon before bowel surgery. Carminative enemas provide relief from gaseous distention. Bulk forming, emollient (wetting), and osmotic laxatives and cathartics help prevent constipation or treat constipation. An enema containing steroid medication may be used for acute inflammation in the lower colon. 38. A guaiac test is ordered for a patient. Which type of blood is the nurse checking for in this patient’s stool? a. Bright red blood b. Dark black blood c. Microscopic d. Mucoid ANS: C Fecal occult blood tests are used to test for blood that may be present in stool but cannot be seen by the naked eye (microscopic). This is usually indicative of a gastrointestinal bleed. All other options are incorrect. Detecting bright red blood, dark black blood, and blood that contains mucus (mucoid) is not the purpose of a guaiac test. DIF:Understand (comprehension)REF:1156 39. A patient is receiving opioids for pain. Which bowel assessment is a priority? a. Clostridium difficile b. Constipation c. Hemorrhoids d. Diarrhea ANS: B Patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. C. difficile occurs from antibiotics, not opioids. Hemorrhoids are caused by conditions other than opioids. Diarrhea does not occur as frequently as constipation. 40. Which nutritional instruction is a priority for the nurse to advise a patient about with an ileostomy? a. Keep fiber low. b. Eat large meals. c. Increase fluid intake. d. Chew food thoroughly. ANS: C Patients with ileostomies will digest their food completely but will lose both fluid and salt through their stoma and will need to be sure to replace this to avoid dehydration. A good reminder for patients is to encourage drinking an 8-ounce glass of fluid when they empty their pouch. This helps patients to remember that they have greater fluid needs than they did before having an ileostomy. A low-fiber diet is not necessary. Eating large meals is not advised. While chewing food thoroughly is correct, it is not the priority; liquid is the priority. 1. A nurse is preparing a bowel training program for a patient. Which actions will the nurse take? (Select all that apply.) a. Record times when the patient is incontinent. b. Help the patient to the toilet at the designated time. c. Lean backward on the hips while sitting on the toilet. d. Maintain normal exercise within the patient’s physical ability. e. Apply pressure with hands over the abdomen, and strain while pushing. f. Choose a time based on the patient’s pattern to initiate defecation-control measures. ANS: A, B, D, F A successful program includes the following: Assessing the normal elimination pattern and recording times when the patient is incontinent. Choosing a time based on the patient’s pattern to initiate defecation-control measures. Maintaining normal exercise within the patient’s physical ability. Helping the patient to the toilet at the designated time. Offering a hot drink (hot tea) or fruit juice (prune juice) (or whatever fluids normally stimulate peristalsis for the patient) before the defecation time. Instructing the patient to lean forward at the hips while sitting on the toilet, apply manual pressure with the hands over the abdomen, and bear down but do not strain to stimulate colon emptying. 2. A nurse is teaching a health class about colorectal cancer. Which information should the nurse include in the teaching session? (Select all that apply.) a. A risk factor is smoking. b. A risk factor is high intake of animal fats or red meat. c. A warning sign is rectal bleeding. d. A warning sign is a sense of incomplete evacuation. e. Screening with a colonoscopy is every 5 years, starting at age 50. f. Screening with flexible sigmoidoscopy is every 10 years, starting at age 50. ANS: A, B, C, D Risk factors for colorectal cancer are a diet high in animal fats or red meat and low intake of fruits and vegetables; smoking and heavy alcohol consumption are also risk factors. Warning signs are change in bowel habits, rectal bleeding, a sensation of incomplete evacuation, and unexplained abdominal or back pain. A flexible sigmoidoscopy is every 5 years, starting at age 50, while a colonoscopy is every 10 years, starting at age 50. [Show More]

Last updated: 1 year ago

Preview 1 out of 90 pages