NCLEX 3 - Module 5 - Elimination Flashcards
The nurse is caring for an older adult client on a medical-surgical unit. The client tells the nurse, “I don’t get any sleep at night because I have to get up and use the bathroom every couple of hours!” When providing an explanation for the nocturia, which statement by the nurse is the most appropriate?
A) “As you get older, there is a decrease in number of nephrons.”
B) “As you get older, there is a decrease in the blood supply to your bladder.”
C) “As you get older, you may have a decreased bladder capacity.”
D) “As you get older, there is a decrease in cardiac output, causing these symptoms.”
C) “As you get older, you may have a decreased bladder capacity.”
Rationale:
Approximately 70% of older women and 50% of older men have to get up two or more times during the night to empty their bladders due to decreased bladder capacity. A decrease in blood supply causes an increase in urine concentration. A decrease in the number of nephrons decreases the filtration rate. A decrease in cardiac output decreases peripheral circulation, which would decrease urinary output day or night.
A client is 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 group of clients on a medical-surgical unit. Which client does the nurse anticipate to be at the greatest risk for alterations in urinary elimination?
A) The client with hypertension who takes a diuretic to manage blood pressure
B) An 80-year-old male client reporting frequent urination at night
C) A 25-year-old female client with low self-esteem
D) A client who had bladder cancer and now has a newly created ileal conduit
B) An 80-year-old male client reporting frequent urination at night
Rationale:
The client who is 80 years old with frequent urination at night may be having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement, causing an alteration in urinary elimination. The 25-year-old experiencing low self-esteem has a psychological problem and will need therapy to find the root of the problem. The client who had bladder cancer and now has an ileal conduit doesn’t have kidney damage, only the bladder removed. Continued urine production through the ileal conduit will need to be observed and assessed frequently by the staff. The client with high blood pressure takes medication to remove excess fluid from the body, and as long as urine elimination increases, there should be no problems.
The nurse is caring for a client with a history of urinary tract infections (UTIs). Which action by the nurse would decrease the risk of the client experiencing future UTIs?
A) Instruct the client to avoid delaying urination.
B) Tell the client to increase caffeine in the diet.
C) Encourage the client to use the pelvic floor muscles to force urine flow.
D) Remind the client to wipe from back to front.
A) Instruct the client to avoid delaying urination.
Rationale:
Suppressing urination increases the risk of urinary tract infections. The pelvic floor muscles should not be used to force urine flow, and doing so is considered a poor toileting habit. The client should wipe from front to back because wiping from back to front would contaminate the urinary meatus. The client should decrease the use of caffeine in the diet because caffeine is a bladder irritant.
The nurse admits a client to the medical unit for a urinary disorder. Which questions are appropriate for the nurse to include when assessing the client’s voiding pattern? Select all that apply.
A) How many times do you urinate in a 24-hour period?
B) Has your pattern of urination changed recently?
C) How often do you get out of bed at night to urinate?
D) What color is your urine?
E) Does your urine have any type of odor?
A) How many times do you urinate in a 24-hour period?
B) Has your pattern of urination changed recently?
C) How often do you get out of bed at night to urinate?
Rationale:
When assessing the client’s voiding pattern it is appropriate for the nurse to ask how many times the client voids in a 24-hour period; if the pattern of urination has change frequently; and how often the client gets out of bed at night to urinate. Questions regarding the color and odor associated with urine are appropriate when assessing urine characteristics.
The nurse is providing care to a client at a local clinic. The nurse suspects that the client is experiencing a urinary tract infection. Which urinalysis result supports the nurse's suspicions? A) pH 5.2 B) Negative glucose C) WBC 10-15 D) Specific gravity 1.012
C) WBC 10-15
Rationale:
A urinalysis typically consists of the pH, glucose, specific gravity, protein, and WBC count. The pH, glucose, and specific gravity are all within normal limits. A normal WBC is 3-4. The WBC count for this client is high and indicates infection.
The nurse is providing care to a client who is experiencing urinary incontinence. Which independent nursing intervention is the most appropriate for this client? A) Encouraging increased fluid intake B) Providing catheter care C) Instructing on self-catheterization D) Teaching hygiene care
D) Teaching hygiene care
Rationale:
Clients with urinary incontinence must be taught hygiene care—sometimes called incontinence care—to protect against tissue breakdown. Encouraging increased fluid intake is appropriate for a client who is dehydrated. Instructing on self-catheterization and providing catheter care is appropriate for a client who is diagnosed with urinary retention.
The nurse is assigned to a postpartum client who had an anesthetic block during labor and delivery. When providing care for this client, which does the nurse anticipate? A) Nocturnal enuresis B) Risk for hyperkalemia C) Residual urine D) Glycosuria
C) Residual urine
Rationale:
The postpartum woman is at risk for overdistention, incomplete bladder emptying, and buildup of residual urine (urine that remains in the bladder after voiding). Glycosuria is expected for a client during pregnancy, not during the postpartum period. Nocturnal enuresis and risk for hyperkalemia are anticipated for older adult clients.
A nurse is caring for a client with congestive heart failure. The healthcare provider prescribes propranolol (Inderal) for the client. Which instruction should the nurse include when administering a beta-adrenergic like propranolol (Inderal) to the client?
A) “This medication must be taken on an empty stomach.”
B) “You will need to discontinue the medication when your symptoms subside.”
C) “This medication causes constipation. You should take a laxative every day.”
D) “It is important to notify the healthcare provider if you experience urinary retention.”
D) “It is important to notify the healthcare provider if you experience urinary retention.”
Rationale:
A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be important for the client to notify the healthcare provider if this occurs. Clients should always check with their healthcare provider before stopping any medication, because there could be some major complications. Constipation has been reported from clients taking propranolol, but a laxative should not be taken every day, as one can become dependent. This medicine should be taken with food, not on an empty stomach, in order to enhance absorption.
The nurse is providing care to a client who is experiencing urinary retention. Which diagnostic tool does the nurse anticipate will be ordered for this client? A) Ultrasonic bladder scan B) Urinalysis C) Intravenous pyelography (IVP) D) Cystoscopy
A) Ultrasonic bladder scan
Rationale:
An ultrasonic bladder scan is the diagnostic test that is used to examine for residual urine. A urinalysis is often used to monitor the urine for infection. An IVP is used to diagnosis a kidney stone. A cystoscopy allows direct visualization of the bladder wall and urethra. It is often used to remove stones.
The nurse is conducting education regarding urinary health at an assisted living facility. When planning topics to include in the session, which are appropriate for the nurse to consider? Select all that apply.
A) Full urinary control usually occurs at 4 or 5 years of age.
B) Due to neuromuscular immaturity in infancy, voluntary urinary control is absent.
C) The kidneys reach maximum size between 35 and 40 years of age.
D) Renal blood flow decreases because of vascular changes and a decrease in cardiac output.
E) Urinary incontinence may occur because of mobility problems or neurological impairments.
D) Renal blood flow decreases because of vascular changes and a decrease in cardiac output.
E) Urinary incontinence may occur because of mobility problems or neurological impairments.
Rationale:
When planning an education session regarding urinary health at an assisted living facility, the nurse would include information that affects the urinary health of the older adult client. Information that is appropriate for the nurse to consider is the decrease in renal blood flow due to vascular changes and that urinary incontinence may occur because of issues with mobility and neurological impairment. While all of the other statements are true regarding urinary health, they are not appropriate for this presentation to older adult clients.
The nurse is providing care to newborns in the nursery. When assessing the newborns' urinary output, which does the nurse anticipate as normal daily urinary output? A) 15-60 mL B) 100-300 mL C) 250-450 mL D) 400-500 mL
A) 15-60 mL
Rationale:
Normal urinary output for the newborn at 1-2 days of age is 15-60 mL per day. Normal urinary output for a newborn 3 to 10 days of age is 100-300 mL per day. The normal output for the newborn at 10 days of age to the infant at 2 months of age is 250-400 mL per day. Normal output for an infant at 2 months of age through 1 year is 400-500 mL per day.
The charge nurse is observing a newly licensed nurse conduct an abdominal assessment on a client admitted with an abdominal mass that is affecting bowel elimination. Which actions by the newly licensed nurse would require the charge nurse to intervene? Select all that apply.
A) Performing palpation before auscultation
B) Performing auscultation before palpation
C) Using inspection, auscultation, percussion, and palpation during the abdominal assessment of the client
D) Using only inspection, percussion, and palpation during the abdominal assessment of the client
E) Using deep palpation during the assessment process
A) Performing palpation before auscultation
D) Using only inspection, percussion, and palpation during the abdominal assessment of the client
E) Using deep palpation during the assessment process
Rationale:
Physical examination of the abdomen in relation to bowel elimination problems includes inspection, auscultation, percussion, and palpation. Auscultation should precede palpation, because palpation can alter peristalsis. Never use deep palpation on a client who has an abdominal mass, renal transplant, or polycystic kidneys, or who is at risk for hemorrhage.
The client is experiencing urinary urgency and frequency. Which medication should the nurse anticipate may be prescribed by the healthcare provider? A) Furosemide B) Bumetanide C) Oxybutynin D) Bethanechol chloride
C) Oxybutynin
Rationale:
Oxybutynin is an anticholinergic that reduces urgency and frequency by blocking muscarinic receptors in the detrusor muscle of the bladder, thereby inhibiting contractions and increasing storage capacity. The nurse would anticipate an order for oxybutynin. Furosemide is a diuretic and works in a specific place within the nephron to increase fluid excretion and prevent fluid reabsorption. Bumetanide is a diuretic and works in a specific place within the nephron to increase fluid excretion and prevent fluid reabsorption. Bethanechol chloride is a cholinergic agent that stimulates bladder contraction and facilitates voiding.
Inadequate fluid intake slows the passage of chyme along the intestines. This slowed passage increases the absorption of fluid from the chyme. How does this decreased intake and increased passage time affect the feces expelled from the body?
A) It is drier and harder than normal.
B) It is more watery and more soft than normal.
C) It is more watery and harder than normal.
D) It is drier and more soft than normal.
A) It is drier and harder than normal.
Rationale:
When fluid intake is inadequate or output is excessive, the passage of chyme slows and the absorption of fluid increases. The end result is feces that is harder and drier than normal. Watery, soft feces is the result of rapid intestinal transit that leads to inadequate fluid absorption.
Clients experiencing diarrhea often lose electrolytes. Which of the following best describes the reason for this loss?
A) Decreased secretion of intestinal mucus inhibits the absorption of electrolytes from the chyme by the intestine.
B) Pathogenic microorganisms that cause diarrhea consume the electrolytes in the chyme, resulting in fewer electrolytes being available for absorption.
C) Diarrhea causes rapid passage of chyme through the large intestine, reducing the time available for absorption of electrolytes.
D) Intestinal bacteria break down electrolytes during diarrhea and make them unfit for absorption by the intestine.
C) Diarrhea causes rapid passage of chyme through the large intestine, reducing the time available for absorption of electrolytes.
Rationale:
Diarrhea causes rapid passage of chyme through the large intestine. This reduces the time available for the large intestine to absorb electrolytes and results in the electrolytes being lost with feces. Diarrhea typically increases secretion of intestinal mucus rather than decreasing it. Pathogenic microorganisms result in inflammation of the mucosa. Bacteria in the intestine cannot break down electrolytes.
A client presents in the emergency department exhibiting signs indicative of the onset of a bowel obstruction. Which bowel sounds should the nurse anticipate when auscultating the client’s abdomen?
A) Gurgling or clicking sounds
B) High-pitched tinkling, rushing, or growling sounds
C) Absence of sounds
D) Continuous medium-pitched hum
B) High-pitched tinkling, rushing, or growling sounds
Rationale:
High-pitched tinkling, rushing, or growling bowel sounds–known as borborygmus–are indicative of the onset of bowel obstruction. Gurgling or clicking sounds are considered normal. Absence of bowel sounds is indicative of late bowel obstruction, not onset of bowel obstruction. A continuous medium pitched hum–called a venous hum–is indicative of a cirrhotic liver.
The nurse is interviewing a client who is experiencing constipation. During the interview, the client states, “I don’t understand what is going on. I feel the urge to go to the bathroom but, once I am in there and I begin pushing with my abdominal muscles, nothing happens.” Which of the following represents the nurse’s best response to the client?
A) “Try taking an over-the-counter medication containing bismuth salts, such as Kaopectate or Pepto-Bismol. If your symptoms don’t subside in 2 days, come back to the office.”
B) “Stop taking all medications until you have reestablished a normal elimination routine. Medication usage often leads to constipation.”
C) “Make sure that you are taking proper care of the skin in the anal area. Skin breakdown can result in hesitancy when defecating.”
D) “Try to avoid straining with the abdominal muscles during defecation. Doing so may actually close the anal sphincter, preventing feces from passing through.”
D) “Try to avoid straining with the abdominal muscles during defecation. Doing so may actually close the anal sphincter, preventing feces from passing through.”
Rationale:
Clients should be instructed to use caution when straining the abdominal muscles during defecation, because it may close the anal sphincter rather than allowing feces to pass through. Bismuth salts are antidiarrheals–not laxatives–and would likely compound the client’s problem. Certain medications can lead to constipation in some clients, but it is not appropriate for the nurse to encourage the discontinuation of all medications. Skin care is a concern for clients who are experiencing diarrhea or fecal incontinence, and is not typically an issue for patients with constipation.
The nurse is reviewing information about four clients who are coming in to the office today due to concerns about bowel elimination. Which of these clients is most likely to have a daily stool softener added to their treatment regimen?
A) A 3-month-old client who is exclusively breastfed
B) A 43-year-old client who takes opioid medication for chronic pain
C) A 92-year-old client who experiences frequent leakage of feces from the anus
D) A 28-year-old client who is anemic and has blood in the stool
B) A 43-year-old client who takes opioid medication for chronic pain
Rationale:
Clients taking opioids have an increased risk of developing constipation and may prevent it by taking daily stool softeners. Breastfed infants typically have soft, liquid stools and would not benefit from a stool softener. Leakage of feces from the anus is indicative of bowel incontinence—not constipation—and would not be treated with a stool softener. Anemia and blood in the stool are indicators of potential bowel cancer or other serious conditions; this client would likely undergo testing rather than be prescribed a stool softener.
The nurse is caring for a client diagnosed with benign prostatic hyperplasia (BPH) who is experiencing an increase in symptoms. Which statement by the client would best explain the source of the increased symptoms?
A) “I have decreased oral intake at night.”
B) “I recently had a vasectomy.”
C) “I am using an over-the-counter cold medication for a cold.”
D) “I am drinking very little caffeine.”
C) “I am using an over-the-counter cold medication for a cold.”
Rationale:
Use of cold medications can increase symptoms because of their anticholinergic properties. Avoiding caffeine and decreasing oral intake at night may resolve symptoms. A vasectomy does not affect the symptoms of BPH.
The nurse is providing care to a client who is diagnosed with benign prostatic hyperplasia (BPH). Which items in the client's health history indicate a risk factor for this diagnosis? Select all that apply. A) Excessive exercise B) Decreased fluid intake C) Diet high in milk D) 70 years of age E) African American ethnicity
D) 70 years of age
E) African American ethnicity
Rationale:
Although the exact cause is unknown, risk factors associated with BPH include increasing age. No link has been made to fluid intake, milk, or exercise.
The nurse is caring for a middle-aged male client who is experiencing urinary retention. The client asks the nurse if it is possible that he is experiencing benign prostatic hyperplasia (BPH). During the client history, the client reports that he is of Japanese descent. 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) “You are considered low-risk for BPH.”
D) “Where did you get an idea that you might have BPH?”
C) “You are considered low-risk for BPH.”
Rationale:
The nurse must always provide honest responses to client questions. The nurse should tell the client that 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 follow-up care for a client was recently diagnosed with benign prostatic hyperplasia (BPH). Which nursing diagnosis is the priority for the nurse to include in the client's plan of care? A) Chronic Pain B) Impaired Urinary Elimination C) Constipation D) Diarrhea
B) Impaired Urinary Elimination
Rationale:
The priority diagnosis for a client diagnoses with BPH is Impaired Urinary Elimination. Acute pain, not chronic pain, is also an appropriate diagnosis. Clients with BPH have problems associated with urinary elimination, not bowel elimination. Constipation and Diarrhea are not appropriate nursing diagnoses for this client.
A client is recovering from prostate surgery on a medical-surgical unit. The client will be ready for discharge within the next few days. Which teaching point is appropriate for this client?
A) The client should not drive for 6 weeks after surgery.
B) The client should call the healthcare provider immediately for any bleeding.
C) The client should incorporate fruit juice in his diet.
D) The client should avoid heavy lifting for 2 weeks after surgery.
C) The client should incorporate fruit juice in his diet.
Rationale:
The client should be encouraged to incorporate fruit juice in his diet to help keep bowel movements regular and soft, as straining for bowel movements after surgery can cause increased pressure in the prostate area. The client may not drive for 2 weeks after surgery. The client is taught to avoid heavy lifting for 4-8 weeks after discharge and to call the doctor for heavy bleeding, though minor bleeding when defecating, coughing, or exercising is normal.
A client is recovering from minimally invasive surgery due to a diagnosis of benign prostatic hyperplasia (BPH). After assessing the client, the nurse expects which outcome for this client? A) Bowel continence B) Absence of pain C) No postoperative treatment D) Urinary continence
D) Urinary continence
Rationale:
After surgery and removal of the catheter, the client should return to urinary continence as expected. The client will need postoperative teaching and will experience some amount of discomfort. Most clients, due to pain and swelling in the area, may have problems with constipation immediately following the surgical intervention.
The nurse is providing care to a client who is diagnosed with mild benign prostatic hyperplasia (BPH). Which lifestyle change is appropriate for this client? A) Increasing caffeine intake B) Increasing alcohol intake C) Urinating at first urge D) Using over-the-counter antihistamines
C) Urinating at first urge
Rationale:
A client who is diagnosed with mild BPH is often treated with lifestyle changes and a “watchful waiting” approach. Urinating at first urge is a lifestyle change that is appropriate for this client. The client should also eliminate caffeine and alcohol from the diet. It is also important for this client to avoid using over-the-counter antihistamines.
A client presents to the urologist with complaints of getting up to urinate several times a night and difficulty starting a stream of urine. After medical testing is completed, a diagnosis of benign prostatic hyperplasia (BPH) is made. After conducting teaching regarding BPH, which statement by the client indicates the need for further education?
A) “Alpha blockers can be used to control my symptoms.”
B) “I know I will get cancer of the prostate because of this.”
C) “As my condition progresses, I may need to consider surgical management.”
D) “There are nonsurgical treatment options available.”
B) “I know I will get cancer of the prostate because of this.”
Rationale:
BPH is a benign condition that is not considered a precursor to cancer. It is caused by an increase in size of the prostate gland and is seen in older males. Alpha blockers will help control the symptoms. There are nonsurgical treatments available, such as medication to shrink the gland along with surgical management, such as resection.
A client is diagnosed with benign prostatic hyperplasia (BPH). Which topics are appropriate for the nurse to include in the teaching session related to the client's condition? Select all that apply. A) Self-care B) Nutrition C) Surgical approaches to treatment D) Pharmacologic approaches to treatment E) Permanent urinary catheterization
A) Self-care
B) Nutrition
C) Surgical approaches to treatment
D) Pharmacologic approaches to treatment
Rationale:
When conducting teaching for a client who is diagnosed with BPH, the nurse will include information regarding self-care, nutrition, surgical approaches for treatment, and pharmacologic approaches for treatment. Permanent urinary catheterization is not an appropriate topic to include in the teaching session.
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 the client wants to know if he is also at risk. Which item in the client's history increases the risk for BPH? A) Decreased 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:
Clients with increased levels of estrogen are at an increased risk for developing BPH. Clients 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, prazosin (Minipress), for the treatment of BPH. When providing care to this client, which assessment is a priority 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.
