Deck 2 - Elimination Flashcards
A client diagnosed with high blood pressure that is not responding to medications. The nurse suspects renal stenosis. When assessing for this condition, which location will the nurse use for auscultation? A) renal arteries B) bladder C) ureters D) internal urethral sphincter
A) renal arteries
Rationale:
The nurse should auscultate the renal arteries by placing the bell of the stethoscope lightly in the areas of the renal arteries, located in the left and right upper abdominal quadrants. Systolic bruits (“whooshing” sounds) may indicate renal artery stenosis.
The nurse is caring for a male client of Japanese descent who is experiencing urinary retention. The client asks the nurse if it is possible that he is experiencing benign prostatic hyperplasia (BPH). Which response by the nurse is the most appropriate?
A) “No, you are not old enough to have BPH.”
B) “Your symptoms are not consistent with BPH.”
C) “Your provider will run some tests; however, you are considered low-risk for BPH”
D) “Where did you get an idea that you might have BPH?”
C) “Your provider will run some tests; however, you are considered low-risk for BPH”
Rationale:
The nurse must always provide honest responses to client questions. Telling the client that the provider will run tests but due to his ethnicity, he is considered low-risk for developing BPH. While age does increase the risk of BPH, it is not the only factor to consider. The client is experiencing urinary retention, which is consistent with BPH. Asking a client where he got that idea is demeaning.
The nurse is providing care to a client in the healthcare clinic. The client’s brother was recently diagnosed with benign prostatic hyperplasia (BPH) and wants to know if he is also at risk. Which item in the client’s history increases the risk for BPH? A) Increased levels of progesterone B) Increased levels of estrogen C) 35 years of age D) Testicle removal due to cancer
B) Increased levels of estrogen
Rationale:
Client’s with increased levels of estrogen are at an increased risk for developing BPH. Client’s younger than 40 years of age are at a decreased risk for BPH. Having testicles removed prior to puberty due to cancer also decreases the risk of BPH.
The client admitted with benign prostatic hyperplasia (BPH) is prescribed an alpha-adrenergic blocker. The client is prescribed prazosin (Minipress) for the treatment of BPH. When providing care to this client, which is a priority assessment related to this medication? A) Blood pressure B) Pain rating C) Respiratory rate D) Temperature
A) Blood pressure
Rationale:
The medication prazosin (Minipress) is an alpha-adrenergic blocker that may cause first-dose phenomenon (severe hypotension and syncope) and tachycardia. When administering this medication to a client diagnosed with BPH, the priority assessment is the client’s blood pressure.
The nurse is providing care to a client who is diagnosed with mild benign prostatic hyperplasia (BPH) who is experiencing urinary retention. Which goal is the most appropriate for this client?
A) The client will increase fluid intake to at least 2-3 liters daily.
B) The client lists over-the-counter medications to be avoided.
C) The client will voice an understanding of the importance of the use of antiembolic stockings and compression devices.
D) The client will use a T-binder or scrotal support properly.
B) The client lists over-the-counter medications to be avoided.
Rationale:
Avoiding over-the-counter medications can lessen or prevent the symptoms associated with mild benign prostatic hyperplasia (BPH). An increased fluid intake can assist in preventing burning on urination after catheter removal and reduces the risk of a urinary tract infection. There is no indication that this client had surgery or had a catheter placed. The use of antiembolic stockings and compression devices reduces the risk of developing a thromboembolism. There is no indication that this client had surgery or is at risk for developing a thromboembolism. The use of a T-binder or scrotal support is for those clients that have undergone surgery and are in need of scrotal support and support of the surgical dressing. There is no indication that this client had surgery or had a catheter placed.
The nurse is attempting to place a urinary catheter for an older adult female client. The nurse is unable to visualize the client’s urinary meatus. Which alternate position for catheterization may be appropriate for this client?
A) Side-lying, lifting up the buttock.
B) Supine, with the HOB elevated at 30°.
C) Supine, with the head of bed (HOB) elevated at 45°.
D) Supine, with the bed flat, legs bent and apart in stirrups.
A) Side-lying, lifting up the buttock.
Rationale:
Because of estrogen-mediated changes in the perineal area of postmenopausal women, the urinary meatus may be very difficult to visualize. The side-lying position, lifting up the buttock, is an alternative that provides better visualization of the urinary meatus. The supine position, regardless of the leg position or height of the bed, would not increase the visualization of the urinary meatus because it is more distal from the changes in the perineal area.
The nurse is caring for a client with a urinary catheter. Which nursing diagnosis is a priority for this client?
A) Chronic Pain related to an obstruction
B) Risk for Impaired Skin Integrity related to incontinence
C) Risk for Infection related to catheter placement
D) Self-Care Deficit related to presence of urinary catheter
C) Risk for Infection related to catheter placement
Rationale:
The client who has a urinary catheter in place is at an increased risk for infection, which is the priority diagnosis. There is no indication that the client is experiencing chronic pain. While there is an increased risk for impaired skin integrity and a self-care deficit, these are not priorities for this client.
The nurse reviewing discharge instructions for a client diagnosed with urinary incontinence resulting from a urinary tract infection. Which statement made by the client indicates the need for further education?
A) “I should drink plenty of water to prevent damage to my kidneys while I am on the antibiotics for the infection.”
B) “Drinking cranberry juice will decrease the risk for developing urinary tract infections.”
C) “I will contact the healthcare provider prior to taking over-the-counter medications while on my antibiotic.”
D) “I will continue to hold my urine while in public so that I do not get another infection.”
D) “I will continue to hold my urine while in public so that I do not get another infection.”
Rationale:
A client who is diagnosed with urinary incontinence secondary to a urinary tract infection will require specific education. The client who states that he or she will hold their urine while in public to decrease the risk of another infection requires more education. Urinary retention is a contributing factor to urinary tract infections. The other statements are appropriate and indicate appropriate understanding of the information presented.
The nurse is providing care of a client who ignores the urge to defecate when at work. The client states, “I don’t like to have a bowel movement anywhere but at home.” Which response by the nurse is the most appropriate?
A) “This is a common practice, and it will strengthen the reflex later.”
B) “You will get the urge later, so you should not worry about it.”
C) “If you continue to ignore the urge to defecate, it can lead to problems.”
D) “It is better to suppress the urge than to suffer embarrassment at work.”
C) “If you continue to ignore the urge to defecate, it can lead to problems.”
Rationale:
When the normal defecation reflexes are inhibited, these conditioned reflexes tend to be progressively weakened. When the urge to defecate is ignored, water continues to be reabsorbed, making the feces hard and difficult to expel. Ignoring the urge repeatedly will eventually cause the urge to be lost. Embarrassment, while unwarranted, is preferable to losing the urge to defecate. Ignoring the urge will not strengthen the reflex later; it will weaken it.
The nurse is caring for a client from another culture. The client tells the nurse that he is constipated. What is the nurse’s initial action?
A) Encourage the client to increase fluid intake and activity.
B) Assess the client’s intake of fiber and fluids.
C) Determine what the client means by constipation.
D) Obtain an order for a laxative and an enema from the physician.
C) Determine what the client means by constipation.
Rationale:
The nurse should first carefully evaluate the client’s concern and question the person as to what is meant by constipation. Determining the client’s normal frequency of bowel movement, consistency of stool, and effort in passing stool is important before deciding to act. The other suggestions–achieving adequate fluid intake, exercising, including fiber in the diet, and using a laxative (and possibly an enema)–may be appropriate once the nurse has adequately assessed the client’s concern of constipation.
The nurse is admitting a child who has had diarrhea for 1 week. Which goal is appropriate for this client when writing the plan of care?
A) The client will increase the amount of sugar in the diet.
B) The client will defecate regularly by discharge.
C) The client will limit fluid intake for 3 days.
D) The client will regain normal stool consistency by discharge.
D) The client will regain normal stool consistency by discharge.
Rationale:
As this client is experiencing diarrhea, the goal will be to regain normal stool consistency, which means less water will be in the stool, resulting in a more formed consistency. Defecating regularly once the diarrhea has subsided can be a goal, but it is too soon for this goal; the problem needs to be corrected first. Since the client is experiencing diarrhea, which can dehydrate the body and promote electrolyte loss, limiting fluid is not appropriate. Increasing the amount of sugar in the diet will just add to the diarrhea.
The home health nurse is providing care to a client with a history of constipation. The healthcare provider prescribed psyllium mucilloid (Metamucil) for the client. After providing medication teaching for this client, which statement indicate the need for further education?
A) “This medication is a lot more natural than other laxatives.”
B) “I may be able to stop my Lipitor with this medication.”
C) “This medication takes several days to work.”
D) “I don’t need to drink extra fluids while I take this medication.”
D) “I don’t need to drink extra fluids while I take this medication.”
Rationale:
Fluids must be increased when clients use psyllium mucilloid (Metamucil). Psyllium mucilloid (Metamucil) takes several days to work, may help to reduce cholesterol levels, and is more natural than other laxatives.
The nurse providing care to a client whose medication therapy for the treatment of renal calculi has failed. Based on this data, which treatment option does the nurse anticipate for this client? A) Lithotripsy B) Surgical removal C) Dietary control D) Initiation of IV fluids
A) Lithotripsy
Rationale:
When medication fails to dissolve stones, the preferred method of treatment is lithotripsy, which is using sound waves to crush the stones so they can be passed out of the urinary system. Depending on the location of the stones, surgery may be the next step in the treatment process. Diet and fluids are used to prevent further stone formation.
A client admitted to the hospital with a diagnosis of inflammatory bowel disease has also been diagnosed with calcium phosphate renal calculi. When planning care for this client, which medication does the nurse anticipate based on the data? A) Potassium citrate B) Indomethacin C) Morphine sulfate D) Hydrochlorothiazide
D) Hydrochlorothiazide
Rationale:
Hydrochlorothiazide is a thiazide diuretic used to prevent the formation of calcium stones. Potassium citrate alkalinizes urine (raises the pH) and is often prescribed to prevent stones that tend to form in acidic urine (uric acid, cystine, and some forms of calcium stones). Indomethacin is a nonsteroidal anti-inflammatory drug (NSAID) that is used to treat pain and discomfort and may reduce the amount of narcotic analgesia required for acute renal colic. Morphine sulfate is a narcotic analgesic used to relieve pain.,
