1During a visit to the pediatrician’s office, a parent inquires about toilet training her daughter
age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when ...
A) the child can recognize bladder fullness.
B) the child can hold the urine for four to five hours.
C) The child cannot control urination until seated on the toilet.
D) The child ignores the desire to void.
A. Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet.
2A client with urine retention related to a complete prostatic obstruction requires a urinary
catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?
A) Suprapubic catheter
B) Indwelling urethral catheter
C) Intermittent urethral catheter
D) Straight catheter
A. A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra.
3Another word for urination?
Micturition
4A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?
A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection.
B) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency.
C)Decreased bladder contractility may lead to urine retention and stasis, which increase the
likelihood of urinary tract infection.
D) Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence.
C
5A nurse is assessing the urine output of a client with Parkinson’s disease who is on levodopa.
Which of the following is a common finding for a client on this medication?
A) The urine may be brown or black.
B) The urine may be blood-tinged.
C) The urine may be green or blue-green.
D) The urine may be orange or orange-red.
A
6A nurse is assessing the urine on a newborn’s diaper. What would be a normal assessment finding?
A) Scanty to no urine
B) Highly concentrated urine
C) Light in color and odorless
D) Dark in color and
C. Infants are born with little ability to concentrate urine. An infant’s urine is usually very light in color and without odor until about 6 weeks of age, when the nephrons are able to control reabsorption of fluids and effectively concentrate urine. Infants do not normally have scanty, highly concentrated, or dark and odorous urine.
7An older woman who is a resident of a long-term care facility has to get up and void several
times during the night. This can be the result of what physiologic change with normal aging?
A) Diminished kidney ability to concentrate urine
B) Increased bladder muscle tone causing urinary frequency
C) Increased bladder contractility causing urinary stasis
D) Decreased intake of fluids during daytime hours
A. To "concentrate urine" means the ability of the kidneys to remove waste products from the blood while retaining the necessary amount of water. This process results in urine that has a higher amount of waste products relative to the water content, which is important for maintaining the body's fluid balance and preventing excessive fluid loss.
As people age, their kidneys may become less efficient at concentrating urine. This can lead to the production of larger volumes of dilute urine, rather than smaller volumes of concentrated urine. The inability to concentrate urine effectively can result in a need to void more frequently, including during the night (nocturia), which may disturb sleep.
8A nurse is delegating the collection of urinary output to an assistant. What should the nurse
tell the assistant to do while measuring the urine?
A) Compare the amount of output with intake.
B) Use a clean measuring cup for each voiding.
C) Tell the client to wash the urethra before voiding.
D) Wear gloves when handling a client’s urine.
D
9An older adult woman has constant dribbling of urine. The associated discomfort, odor, and
embarrassment may support which of the following nursing diagnoses?
A) Social Isolation
B) Impaired Adjustment
C) Defensive Coping
D) Impaired Memory
A
10A male client who has had outpatient surgery is unable to void while lying supine. What can
the nurse do to facilitate his voiding?
A) Assist him to a standing position.
B) Tell him he has to void to be discharged.
C) Pour cold water over his genitalia.
D) Ask his wife to assist with the urinal.
A
11A PVR (post voiding residual) less than what is normal
50mL
12A client is taking diuretics. What should the nurse teach the client about his urine?
A) Urinary output will be decreased.
B) Urinary output will be increased.
C) Urine will be a pale yellow color.
D) Urine may be brown or black.
C
13A nurse is caring for a client who is being treated for bladder infection. The client complains
to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the
client’s condition?
A) Anuria
B) Oliguria
C) Polyuria
D) Dysuria
D
14The home health nurse is caring for an older adult woman living alone at home who is
incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for
this client?
A) Risk for activity intolerance
B) Risk for impaired skin integrity
C) Risk for infection
D) Risk for falls
B
15During defecation, the client experiences decreased cardiac output related to the Valsalva
maneuver. After the Valsalva maneuver, the nurse assesses the client’s vital signs and expects to observe which of the
following?
A) An increase in the client’s blood pressure
B) A decrease in the client’s blood pressure
C) An increase in the client’s respiratory rate
D) A decrease in the client’s respiratory rate
A. When an individual bears down to defecate, the increased pressures in the abdominal and thoracic cavities result in a decreased blood flow and a temporary decrease in cardiac output. Once the bearing down ceases, the pressure is lessened, and a larger than normal amount of blood returns to the heart; this act elevates the client’s blood pressure.
16 hospitalized toddler, previously bowel trained, has been having incontinent stools. What
would the nurse tell the parents about this behavior?
A) “When he does this, scold him and he will quit.”
B) “I don’t understand why this child is losing control.”
C) “This is normal when a child this age is hospitalized.”
D) “I will have to call the doctor and report this behavior.”
C
17The following foods are a part of a client’s daily diet: high-fiber cereals, fruits, vegetables,
2,500 mL of fluids. What would the nurse tell the client to change?
A) Decrease high-fiber foods
B) Decrease amount of fluids
C) Omit fruits if eating vegetables
D) Nothing; this is a good diet
D
18A nurse is conducting an abdominal assessment. What is the rationale for palpating the
abdomen last in the sequence when conducting an abdominal assessment?
A) It is the most painful assessment method
B) It is the most embarrassing assessment method
C) To allow time for the examiner’s hands to warm
D) It disturbs normal peristalsis and bowel motility
D
19What is occult blood?
A) Bright red visible blood
B) Dark black visible blood
C) Blood that contains mucus
D) Blood that cannot be seen
D. Occult blood in the stool is blood that is hidden in the specimen or cannot be seen on gross examination. It can be detected with simple screening tests, such as a hematest.
20Which is an expected outcome for a client undergoing a bowel training program?
A) Have a soft, formed stool at regular intervals without a laxative.
B) Continue to use laxatives, but use one less irritating to the rectum.
C) Use oil-retention enemas on a regular basis for elimination.
D) Have a formed stool at least twice a day for two weeks.
(got this right but did not understand)
A. Clients who have chronic constipation and impaction, and those who are incontinent of stool, may benefit from a bowel training program. The purpose of this program is to manipulate factors within the client’s control (such as exercise or fluid intake) to produce the elimination of a soft, formed stool at regular intervals without a laxative.
21A nurse is documenting the appearance of feces from a client with a permanent ileostomy.
Which of the following 21. would she document?
A) “Ileostomy bag half filled with liquid feces.”
B) “Ileostomy bag half filled with hard, formed feces.”
C) “Colostomy bag intact without feces.”
D) “Colostomy bag filled with flatus and feces.”
Ans: A
Feedback:
The client with an ileostomy (temporary or permanent) has an opening into the small intestine. Because feces do not reach the large intestine, water is not absorbed, and the feces will be liquid.
22A nurse is assessing the stoma of a client with an ostomy. What would the nurse assess in a normal, healthy stoma?
A) Pallor
B) Purple-blue
C) Irritation and bleeding
D) Dark red and moist
D. Feedback:
The ostomy stoma should be dark pink to red and moist. Abnormal findings include paleness (possible anemia), purple- blue color (possible ischemia), or bleeding.
23A nurse is caring for a client who is postoperative Day 1 for a temporary colostomy. The nurse
assesses no feces in the collection bag. What should the nurse do next?
A) Notify the physician immediately.
B) Ask another nurse to check her findings.
C) Nothing; this is normal.
D) Recheck the bag in two hours.
C. Typically, a colostomy does not produce drainage or feces until normal peristalsis returns after surgery, usually within two to five days.
24A nurse is assessing a client with constipation and severe rectal pain. Which of the following
actions should the nurse
25. perform to determine the presence of fecal impaction?
A) Inserted a lubricated, gloved finger into the rectum.
B) Obtain a sharp intestinal x-ray.
C) Insert a lubricated rectal tube into the rectum.
D) Administer an oil retention enema into the rectum.
A. The nurse should insert a lubricated, gloved finger into the rectum to determine the presence of fecal impaction. Fecal impaction occurs when a large, hardened mass of stool interferes with defecation. Obtaining a sharp intestinal x-ray is not a good idea because the barium retained in the intestine causes fecal impaction. Insertion of a rectal tube and administration of an oil retention enema are measures used to remove hardened stool,
not assess it.
25The nurse is assessing a client with abdominal complaints. The nurse performs deep palpation
of the abdomen for which reason?
A) Detect abdominal masses
B) Determine abdominal firmness
C) Assess softness of abdominal muscles
D) Assess degree of abdominal distention
A. The purpose of the deep palpation is to detect abdominal masses. Light palpation of the abdomen helps to determine the firmness or softness of the abdominal muscles and the degree of abdominal distention.
26A nurse is providing care to a client who has undergone a colonoscopy. Which of the
following would be most appropriate for the nurse to do after the procedure?
A) Avoid giving solid food
B) Administer a laxative to the client
C) Monitor for rectal bleeding
D) Limit oral fluid intake
C. The nurse should monitor the client for rectal bleeding after a colonoscopy. The nurse should provide rest and offer food and fluids as allowed. The evening before the procedure, solid foods are avoided and liquids are encouraged. Laxatives are also given before the procedure.
27During a home visit, the nurse learns that the client ensures a daily bowel movement
with the help of laxatives. The client feels that deviation from a bowel movement
every day is unhealthy. Which nursing diagnosis would the nurse 28. most likely identify?
A) Constipation
B) Perceived constipation
C) Risk of constipation
D) Bowel incontinence
B The most appropriate nursing diagnosis for the client is perceived constipation, because the client has made a self- diagnosis of constipation and ensures a daily bowel movement through the abuse of laxatives. Constipation may be diagnosed in a client if there is a decrease in the normal frequency of defecation accompanied by a difficult or incomplete passage of stool (and/or passage of excessively hard, dry stool). Risk of constipation can be diagnosed if a client exhibits factors that predispose him or her for developing constipation. Bowel incontinence would be indicated if the client was experiencing an involuntary passage of stool.
28A nurse assesses the abdomen of a client before and after administering a small-volume
cleansing enema. What condition would be an expected finding?
A) Increased bowel sounds
B) Abdominal tenderness
C) Areas of distention
D) Muscular resistance
A. The goal of a cleansing enema is to increase peristalsis, which should increase bowel sounds.
29A physician orders a retention enema for a client to destroy intestinal parasites. Which of the
following enemas would be 31. indicated for this client?
A) Oil retention enema
B) Carminative enema
C) Anthelmintic enema
D) Nutritive enema
C. Anthelmintic enemas are administered to destroy intestinal parasites. Oil retention enemas help to lubricate the stool and intestinal mucosa, making defecation easier. Carminative enemas help to expel flatus from the rectum and relieve distention. Nutritive enemas are administered to replenish fluids and nutrition rectally.
30A nurse is ordered to perform digital removal of stool on a client with stool impaction. Which
of the following is an appropriate step in this procedure?
A) Position the client in supine position as dictated by client comfort and condition.
B) Insert generously lubricated finger gently into the anal canal, pointing away from the umbilicus.
C) Gently work the finger around and into the hardened mass to break it up and then remove pieces of it.
D) Instruct the client not to bear down while extracting feces to prevent vagal response.
C. For digital removal of stool: Position the client on the left side (Sims’ position), as dictated by client comfort and condition. Generously lubricate index finger with water-soluble lubricant and insert finger gently into anal canal, pointing toward the umbilicus. Gently work the finger around and into the hardened mass to break it up and then remove pieces of it. Instruct the client to bear down, if possible, while extracting feces, which will ease in removal.
31 nurse assessing a client with an ostomy appliance documents the condition “prolapse” in the
client chart and notifies the physician. Which of the following statements describes this condition?
A) The peristomal skin is excoriated or irritated because the appliance is cut too large.
B) The system has leaks or poor adhesion leading to noticeable odor.
C) The bag continues to come loose and become inverted.
D) The stoma is protruding into the bag and may become twisted.
D. During prolapse, the stoma is protruding into the bag. The nurse should have the client rest for 30 minutes and, if stoma is not back to normal size within that time, notify the physician. If stoma stays prolapsed, it may twist, resulting in impaired circulation to the stoma.
32A nurse is following a physician’s order to irrigate the NG tube of a client. Which of the
following is a recommended guideline in this procedure?
A) Assist client to 30- to 45-degree position, unless this is contraindicated.
B) Draw up 60 mL of saline solution (or amount indicated in the order or policy) into syringe.
C) If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the blue air vent.
D) If unable to irrigate the tube, reposition client and attempt irrigation again; inject 20 to 30 mL of air and aspirate again.
A. To irrigate an NG tube, assist the client to 30- to 45-degree position, unless this is contraindicated. Pour the irrigating solution into the container and draw up 30 mL of saline solution (or amount indicated in the order or policy) into syringe. If Salem sump or double-lumen tube is used, make sure that syringe tip is placed in the drainage port and not in the blue air vent. If unable to irrigate the tube, reposition the client and attempt irrigation again. Inject 10 to 20 mL of air and aspirate again.
33Then nurse is preparing to apply a fecal incontinence pouch. Arrange the following steps in the correct order.
1. Cleanse entire perianal area and pat dry.
2. Apply skin protectant and allow it to dry.
3. Separate buttocks and apply the pouch to the anal area.
4. Attach the pouch to a urinary drainage bag.
5. Hang the drainage bag below the patient.
A) 2,3,4,5,1
B) 3,4,5,1,2
C) 1,2,3,4,5
D) 5,4,3,2,1 (you got this right)
C