NCLEX - W11 - Elimination Flashcards
A nurse is caring for a patient with an indwelling urinary catheter. Which of the following actions should the nurse take to prevent a catheter-associated urinary tract infection (CAUTI)?
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A. Irrigate the catheter with sterile saline solution every 8 hours.
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B. Disconnect the catheter from the drainage bag to obtain a urine specimen.
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C. Keep the drainage bag below the level of the bladder.
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D. Change the catheter every 72 hours.
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Answer: C. Keep the drainage bag below the level of the bladder.
Rationale: Keeping the drainage bag below the level of the bladder prevents urine from flowing back up into the bladder, reducing the risk of infection. Routine irrigation is not recommended, and disconnecting the catheter should be avoided. While changing the catheter might be necessary in certain situations, it’s not the primary method for preventing CAUTI.
A patient reports frequent urination at night. The nurse should document this finding as:
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A. Dysuria
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B. Nocturia
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C. Polyuria
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D. Oliguria
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Answer: B. Nocturia
Rationale: Nocturia specifically refers to frequent urination during the night. Dysuria is painful urination, polyuria is excessive urine production, and oliguria is diminished urine output.
Which of the following laboratory values would indicate a potential problem with kidney function?
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A. Elevated blood urea nitrogen (BUN)
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B. Decreased urine specific gravity
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C. Presence of glucose in the urine
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D. All of the above
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Answer: D. All of the above
Rationale: Elevated BUN and creatinine levels in the blood are indicators of impaired kidney function. Low urine specific gravity can indicate the kidneys are not concentrating urine effectively. The presence of glucose in the urine can point towards diabetes, which can affect kidney function.
A nurse is caring for a patient who is experiencing urinary retention. Which of the following interventions should the nurse perform first?
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A. Insert an indwelling urinary catheter.
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B. Encourage the patient to drink plenty of fluids.
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C. Assess the patient’s bladder for distention.
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D. Administer a diuretic medication.
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Answer: C. Assess the patient’s bladder for distention.
Rationale: Assessing the patient’s bladder for distention is the priority nursing action. This will help confirm urinary retention and guide further interventions. While catheterization may be necessary, assessment should come first. Encouraging fluids and administering diuretics are not appropriate for a patient retaining urine.
A patient with stress incontinence is starting a bladder training program. The nurse should instruct the patient to:
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A. Restrict fluid intake to 1,000 mL per day.
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B. Perform Kegel exercises several times a day.
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C. Void every hour, whether or not they feel the urge.
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D. Take a diuretic medication to increase urine output.
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Answer: B. Perform Kegel exercises several times a day.
Rationale: Kegel exercises strengthen pelvic floor muscles, which helps improve bladder control in stress incontinence. Restricting fluids is not recommended as it can lead to dehydration and concentrated urine, potentially irritating the bladder. Voiding on a fixed schedule is more applicable to urge incontinence. Diuretics would worsen incontinence
A nurse is caring for a patient who has undergone a urinary diversion surgery. Which of the following actions is most important for the nurse to take?
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A. Monitor the patient’s urine output closely.
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B. Assess the patient’s stoma for signs of infection.
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C. Teach the patient how to empty the ostomy pouch.
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D. Provide emotional support to the patient.
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Answer: B. Assess the patient’s stoma for signs of infection.
Rationale: Assessing the stoma for infection is a priority post-operatively. While all the other options are important aspects of care, a potential infection poses an immediate risk and needs prompt attention.
Which of the following is a normal finding in a urinalysis?
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A. Presence of ketones
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B. Urine pH of 6.0
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C. Presence of bacteria
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D. Urine specific gravity of 1.040
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Answer: B. Urine pH of 6.0
Rationale: A urine pH between 4.6 and 8.0 is considered normal. Ketones, bacteria, and a specific gravity of 1.040 indicate abnormalities.
Which of the following actions by a female patient could increase her risk of developing a urinary tract infection?
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A. Wiping from front to back after voiding
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B. Drinking cranberry juice daily
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C. Taking bubble baths frequently
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D. Voiding immediately after sexual intercourse
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Answer: C. Taking bubble baths frequently
Rationale: Bubble baths can irritate the urethra and introduce bacteria, increasing the risk of UTIs. Wiping front to back, drinking cranberry juice (though its effectiveness is debated), and voiding after intercourse are all preventative measures against UTIs.
A nurse is assessing a patient’s understanding of how to perform Kegel exercises. The nurse knows the patient understands when they state:
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A. “I should hold the contraction for 5 to 10 seconds and then relax for 5 to 10 seconds.”
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B. “I should perform Kegel exercises while urinating.”
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C. “I should only perform Kegel exercises when I feel the urge to urinate.”
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D. “Kegel exercises are only for women.”
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Answer: A. “I should hold the contraction for 5 to 10 seconds and then relax for 5 to 10 seconds.”
Rationale: This is the correct technique for Kegel exercises. Performing them while urinating can cause backflow of urine. They can be done at any time, not just when feeling the urge to urinate, and men can benefit from Kegel exercises as well.
A nurse is caring for a patient who is experiencing urinary incontinence. Which of the following should be included in the patient’s plan of care?
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A. Bladder training
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B. Pelvic floor muscle exercises
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C. Skin care
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D. All of the above
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Answer: D. All of the above
Rationale: All of these interventions are important for managing urinary incontinence. Bladder training and Kegel exercises help improve bladder control, and skin care is essential to prevent breakdown from urine contact.
A patient reports having fewer than three bowel movements per week and straining to pass hard, dry stools. These findings are consistent with which diagnosis?
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A. Diarrhea
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B. Fecal impaction
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C. Constipation
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D. Ileus
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Answer: C. Constipation
Rationale: Infrequent bowel movements, hard stools, and straining are characteristic symptoms of constipation. Diarrhea is characterized by loose, watery stools. Fecal impaction is a severe form of constipation where stool is lodged in the rectum. Ileus is a lack of peristalsis in the intestines.
Which of the following medications can cause constipation?
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A. Opioids
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B. Laxatives
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C. Antibiotics
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D. Diuretics
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Answer: A. Opioids
Rationale: Opioids are known to slow down bowel motility, leading to constipation. Laxatives are used to relieve constipation. Antibiotics can sometimes cause diarrhea. Diuretics primarily affect urine output.
A nurse is caring for a patient who has fecal impaction. The nurse anticipates the healthcare provider to order:
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A. A bulk-forming laxative
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B. An antidiarrheal medication
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C. Digital removal of stool
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D. An enema
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Answer: C. Digital removal of stool
Rationale: For severe constipation with impaction, digital removal of stool may be necessary to relieve the obstruction. Bulk-forming laxatives and enemas are generally not effective for impaction. Antidiarrheal medications are not used for constipation.
Which of the following foods should the nurse recommend to a patient who is experiencing constipation?
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A. White bread
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B. Bananas
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C. Cheese
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D. Prunes
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Answer: D. Prunes
Rationale: Prunes are a good source of fiber, which adds bulk to stool and helps with bowel movements. White bread, bananas, and cheese are not high in fiber.
A nurse is teaching a patient about how to prevent constipation. Which of the following instructions should the nurse include?
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A. “Drink at least eight glasses of water per day.”
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B. “Engage in regular physical activity.”
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C. “Eat a diet high in fiber.”
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D. All of the above
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Answer: D. All of the above
Rationale: Staying hydrated, being physically active, and consuming a high-fiber diet are all important for promoting regular bowel movements and preventing constipation.
A patient with a new colostomy expresses anxiety about caring for the ostomy. Which nursing response is most appropriate?
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A. “Don’t worry, it’s not that difficult.”
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B. “I understand your concerns. Let’s discuss any questions you have.”
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C. “You’ll get used to it eventually.”
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D. “It’s important to keep the area clean.”
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Answer: B. “I understand your concerns. Let’s discuss any questions you have.”
Rationale: Acknowledging the patient’s anxiety and offering to address their concerns is a therapeutic response. Dismissing their worries or providing generic advice without addressing their specific anxieties is not helpful.
Answer: B. “I understand your concerns. Let’s discuss any questions you have.”
Rationale: Acknowledging the patient’s anxiety and offering to address their concerns is a therapeutic response. Dismissing their worries or providing generic advice without addressing their specific anxieties is not helpful.
A nurse is assessing a patient’s stoma. Which finding should be reported to the healthcare provider immediately?
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A. A stoma that is pink and moist
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B. A stoma that is beefy red
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C. A stoma that is purple and dry
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D. A stoma that is slightly raised above skin level
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Answer: C. A stoma that is purple and dry
Rationale: A purple or black, dry stoma suggests inadequate blood supply, which is a serious complication. A pink and moist stoma is normal. A beefy red stoma may indicate some irritation but is not necessarily an emergency. A slightly raised stoma is typical.
Which of the following tests can be used to screen for colon cancer?
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A. Fecal occult blood test
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B. Colonoscopy
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C. Both A and B
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D. Neither A nor B
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Answer: C. Both A and B
Rationale: Both fecal occult blood tests (which check for hidden blood in stool) and colonoscopies (which allow visual examination of the colon) are used to screen for colon cancer.
Which type of enema is generally considered the safest?
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A. Tap water enema
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B. Soapsuds enema
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C. Normal saline enema
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D. Hypertonic solutions enema
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Answer: C. Normal saline enema
Rationale: Normal saline enemas have the same osmolarity as body fluids, making them the safest option. Tap water enemas can cause electrolyte imbalances. Soapsuds enemas can be irritating. Hypertonic solutions can draw water into the bowel, potentially causing discomfort.
A nurse is caring for a patient with diarrhea. Which of the following interventions should the nurse prioritize?
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A. Administer a bulk-forming laxative.
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B. Monitor the patient for signs of dehydration.
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C. Encourage the patient to drink plenty of milk.
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D. Restrict the patient’s fluid intake.
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Answer: B. Monitor the patient for signs of dehydration.
Rationale: Diarrhea can lead to dehydration quickly, so monitoring for signs of dehydration (such as dry mouth, decreased urine output, dizziness) is crucial. Bulk-forming laxatives are used for constipation. Milk can sometimes worsen diarrhea. Fluid restriction is not appropriate for diarrhea.
What minimum hourly urine output should a nurse report to the healthcare provider?
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A. 10 mL
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B. 20 mL
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C. 30 mL
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D. 40 mL
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Answer: C. 30 mL
Rationale: A urine output less than 30 mL per hour is concerning and suggests potential kidney dysfunction. It’s important to report this finding promptly.
Which nursing intervention helps promote normal bowel elimination?
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A. Encouraging the patient to ignore the urge to defecate
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B. Providing privacy during toileting
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C. Restricting fluid intake
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D. Administering a constipating medication
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Answer: B. Providing privacy during toileting
Rationale: Many people find it easier to have a bowel movement when they have privacy. Ignoring the urge to defecate can lead to constipation. Restricting fluids can also contribute to constipation. Constipating medications are not used to promote bowel elimination.
What should a nurse do with the first void when collecting a 24-hour urine specimen?
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A. Include it in the collection container
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B. Discard it and then begin collecting urine
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C. Send it to the laboratory for immediate analysis
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D. Use it for a routine urinalysis
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Answer: B. Discard it and then begin collecting urine
Rationale: The 24-hour urine collection starts after the first void is discarded. This ensures that the collection accurately reflects urine produced over a full 24-hour period.
A patient reports burning upon urination. This symptom is documented as:
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A. Polyuria
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B. Oliguria
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C. Dysuria
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D. Nocturia
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Answer: C. Dysuria
Rationale: Dysuria is the medical term for pain or burning during urination, often associated with urinary tract infections.
