Elimination Flashcards
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?
A. Eating more protein is optimal prior to testing.
B. One stool specimen is sufficient for testing.
C. A red color change indicates a positive test.
D. The specimen cannot be contaminated with urine
D. CORRECT: For fecal occult blood testing, instruct the client not to contaminate the stool specimens with water or urine
A nurse is providing dietary teaching for a
client who reports constipation. Which of the following foods should the nurse recommend?
A. Macaroni and cheese
B. One medium apple with skin
C. One cup of plain yogurt
D. Roast chicken and white rice
B. CORRECT: One medium apple with the skin is the best food source to recommend because it contains 4.4 g of fiber
A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply.)
A. Bradycardia
B. Hypotension
C. Elevated temperature
D. Poor skin turgor
E. Peripheral edema
B. CORRECT: Prolonged diarrhea leads to dehydration. Expect the client to have a decrease in blood pressure.
C. CORRECT: Prolonged diarrhea leads to dehydration. Expect the client to have an increased temperature.
D. CORRECT: Prolonged diarrhea leads to dehydration. Expect the client to have poor skin turgor.
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?
A. Have the client hold their breath briefly and bear down.
B. Clamp the enema tubing.
C. Remind the client that cramping is common at this time.
D. Raise the level of the enema fluid container
B. CORRECT: Clamp the enema tubing for 30 seconds to reduce intestinal spasms.
A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.)
A. Warm the enema solution prior to instillation.
B. Position the client on the left side with
the right leg flexed forward.
C. Lubricate the rectal tube or nozzle.
D. Slowly insert the rectal tube about 5 cm (2in).
E. Hang the enema container 61 cm (24 in) above the client’s anus
A. CORRECT: Warm the enema solution because cold fluid can cause abdominal cramping, and hot fluid can injure the intestinal mucosa.
B. CORRECT: Place the client in this position to promote a downward flow of solution by gravity along the natural anatomical curve of the sigmoid colon.
C. CORRECT: Lubricate the tubing to prevent trauma or irritation to the rectal mucosa.
A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.)
A. Limit total daily fluid intake.
B. Decrease or avoid caffeine.
C. Take calcium supplements.
D. Avoid drinking alcohol.
E. Use the Credé maneuver.
B. CORRECT: Caffeine is a bladder irritant and can worsen stress incontinence.
D. CORRECT: Alcohol is a bladder irritant and can worsen stress incontinence
A client who has an indwelling catheter
reports a need to urinate. Which of the
following actions should the nurse take?
A. Check to see whether the catheter is patent.
B. Reassure the client that it is not possible for them to urinate.
C. Recatheterize the bladder with a larger‑gauge catheter.
D. Collect a urine specimen for analysis
A. CORRECT: A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate
A nurse is caring for a client who has a prescription for a 24‑hr urine collection. Which of the following actions should the nurse take?
A. Discard the first voiding.
B. Keep the urine in a single container at room temperature.
C. Dispose of the last voiding.
D. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container
A. CORRECT: Discard the first voiding of the 24‑hr urine specimen, and note the time
A nurse is reviewing factors that increase the risk of urinary tract infections (UTIs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.)
A. Frequent sexual intercourse
B. Lowering of testosterone levels
C. Wiping from front to back to clean the perineum
D. Location of the urethra closer to the anus
E. Frequent catheterization
A. CORRECT: Having frequent sexual intercourse increases the risk of UTIs in all clients.
D. CORRECT: The close proximity of the urethra to the anus is a factor that increases the risk of UTIs.
E. CORRECT: Frequent catheterization and the use of indwelling catheters are risk factors for UTIs
A nurse is preparing to initiate a bladder‑retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.)
A. Restrict the client’s intake of fluids during the daytime.
B. Have the client record urination times.
C. Gradually increase the urination intervals.
D. Remind the client to hold urine until the next scheduled urination time.
E. Provide a sterile container for urine
B. CORRECT: Ask the client to keep track of urination times as a record of progress toward the goal of 4‑hr intervals between urination.
C. CORRECT: Gradually increasing the urination intervals helps the client progress toward the goal of 4‑hr intervals between urination.
D. CORRECT: Remind the client to hold urine until the next scheduled urination time as part of progressing toward the goal of 4‑hr intervals between urination
Define Dysuria
Painful urination, usually due to a UTI or trauma
Define Nocturnal Enuresis
Nighttime bedwetting; common in children, but may occur in adults who consume too much alcohol or caffeine
