Flashcards in Urinary and Bowel Prep U Q's Deck (25):
A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last
After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?
Hyperactive bowel sounds
The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?
The student sequenced from auscultation to inspection, and percussion to palpation.
A cleansing enema has been ordered for the client to draw water into the bowel. Which type of solution does the nurse gather?
A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients that follow which diet?
a diet lacking in fruits and vegetables
A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?
Wash it with a mild cleanser and water
The nurse is caring for a client with a stoma placed before the terminal ileum. Which vitamin does the nurse anticipate will be ordered?
The nurse is administering a cleansing enema when the client reports cramping. What is the appropriate nursing action?
Clamp the tube for a brief period.
The nurse is preparing to administer a large-volume enema to an adult client. How far should the nurse insert the tubing?
3 inches (7.5 cm)
The proliferation of Clostridium difficile causes:
The nurse is administering a large-volume cleansing enema to a client who reports severe cramping upon introduction of the enema solution. What would be the nurse’s next action?
Lower solution container and check temperature and flow rate
The nurse is caring for a client with a Foley catheter in place who has a prescription for a sterile urine specimen for culture and sensitivity. The nurse implements which techniques to obtain the prescribed urine specimen?
• The nurse uses a syringe to withdraw urine from the port.
• The nurse dons clean gloves and cleanses the port with aseptic solution.
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?
intermittent urethral catheter
To promote drainage of a client’s Foley catheter, which intervention would be most important for the nurse to implement?
Confirming the catheter tubing is not lying under the client
Types of incontinence
stress incontinence: following weakening of perineal and sphincter muscle tone secondary to giving birth. Reflex incontinence is caused by damage to motor and sensory tracts in the lower spinal cord secondary to trauma. Urge incontinence is caused by bladder irritation secondary to infection. Functional incontinence is caused by impaired mobility, impaired cognition, or an inability to communicate.
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?
first thing in the morning
Normal urination volumes
Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?
cloudy, foul odor
The nurse has an order to obtain a 24-hour urine from a client. Which of the following instructions would be accurate for collection of the specimen?
“Discard your first urine and begin the collection after that.”
What is functional incontinence?
Functional incontinence is urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, or loss of memory or disorientation. Also, takes place when attempting to overcome obstacles, such as transferring from the wheelchair to the bed.
What are some healthy ways to manage incontinence?
Limiting fluid intake is not a healthy practice, and clients should be encouraged not to use fluid restriction as an incontinence management strategy. Promoting fluid intake is beneficial for most clients who do not possess a contraindication, and it is appropriate and useful to take diuretics in the morning to avoid nocturia. Even though it may involve work for both the client and the nurse, clients who want to use a bathroom or commode rather than an adult absorbent brief should be encouraged to do so.
The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?
“Void a small amount, stop, and discard it.”
A nurse is caring for a client with an external condom catheter. What is a guideline for applying and caring for this type of catheter?
Fasten the condom securely enough to prevent leakage without constricting the blood vessels