Deck 51: Elimination

Question 1

Which statement presents accurate information about the characteristics of human urine?

A) Light amber-colored urine is seen in the case of dehydration.
B) Strong ammonia-like odor is normal in freshly voided urine.
C) Change in the normal color of urine may be caused by medications.
D) Orange-brown colored urine is seen in the case of overhydration.

Answer 1

Change in the normal color of urine may be caused by medications.

Question 2

The nurse is taking care of a client who weighs 50 kg. What is the estimated amount of urine the client would be expected to excrete in 24 hours?

A) 500 mL
B) 750 mL
C) 1,200 mL
D) 1,550 mL

Answer 2

1,200 mL

Question 3

What amount of urine collected in the bladder will normally trigger the urge to void?

A) 250 mL
B) 350 mL
C) 400 mL
D) 500 mL

Answer 3

250 mL

Question 4

A client diagnosed with diabetes has to void urine more often than usual. However, the
Volume of urine is not increased. What term should the nurse use to describe the client's condition in the electronic medical record?

A) Incontinence
B) Dysuria
C) Frequency
D) Polyuria

Question 5

The nurse notices a bright red streak in the stool of an adult client. What is the most likely cause of this observation?

A) Hemorrhage in the stomach
B) Esophageal varices
C) Presence of microorganisms
D) Bleeding in the rectum

Question 6

A client is suspected of having a gastrointestinal problem from a location in the stomach. What stool characteristic supports that suspicion?

A) Dark, tarry
B) Frothy
C) Yellowish or greenish
D) Bright red streak

Question 7

Which factor most frequently contributes to a client's chronic constipation?

A) Insufficient exercise
B) Some type of medications, such as morphine
C) Occurs after surgery as a result of anesthesia and drying agents
D) Ignores the impulse to empty the rectum on a regular basis

Question 8

Which factors contribute to a client's continuous diarrhea? Select all that apply.

A) Chronic irritation of the colon
B) Food poisoning
C) Parasitic infection
D) Emotional distress
E) Strenuous exercise

Question 9

Which characteristics are associated with fecal impaction? Select all that apply.

A) Severe abdominal discomfort
B) Abdomen is soft when palpated
C) Feeling of abdominal pressure
D) Inability to empty bowel completely
E) Diarrhea

Question 10

A 25-year-old male client who is prescribed bathroom privileges has acute diarrhea but is feeling weak and requires assistance in going to the bathroom. What role should the nurse play in such a situation?

A) Assure safety by providing a bedpan to the client instead.
B) Assist the client to the bathroom as required.
C) Support the client when he is sitting on the toilet seat.
D) Provide the client with instructions and easy access to the call signal while in the bathroom.

Question 11

A client who is on bed rest is unable to void when using the bedpan. What nursing measures should the nurse implement to help the client urinate? Select all that apply.

A) Put the client's hand in cold water.
B) Pour warm water over the genitalia.
C) Assist the client in setting upright on the bedpan.
D) Let the client hear the sound of running water.
E) Have the client stand at the bedside prior to voiding.

Question 12

Which statement accurately describes nursing care for a client prescribed an external catheter?

A) Remove the catheter from the bag connection once every day and swab with antiseptics.
B) Open the drainage port and allow the urine to drain out of the bag at the end of 24 hours.
C) Wash the leg bag in hot soapy water; rinse it thoroughly; and spread it flat to dry.
D) Remove the sheath and expose the penile skin to the air at intervals during the day.

Question 13

Which is the correct sequence for bladder training with closed urinary drainage?
1) Open the clamp and allow the bladder to drain by gravity into the drainage bag. Repeat the procedure.
2) Explain the procedure and position the client in the supine position.
3) Record the procedure on the client's electronic medical record, including urinary output. Clamp the catheter tubing for 1 to 2 hours.
4) Put on disposable gloves and clamp the catheter tubing for 1 to 2 hours.

A) 1, 3, 2, 4
B) 2, 4, 1, 3
C) 3, 1, 4, 2
D) 4, 2, 3, 1

Question 14

What information accurately describes a tap water enema? Select all that apply.

A) It is a type of purgative enema
B) It softens the stool in the large intestines
C) It destroys intestinal parasites
D) It stimulates intestinal peristalsis
E) It is a colon irritant

Question 15

Which is the best description of a carminative enema?

A) Consists of a small amount of olive or cottonseed oil, given to protect or soothe the mucous membrane of the colon.
B) Introduces enough fluid into the colon to soften feces, stimulate peristalsis, and produce a bowel movement that empties the rectum and lower colon.
C) Medication is inserted into the rectum in combination with a small amount of oil or saline to reduce its irritating effect and to lessen the client's desire to expel it.
D) Given to stimulate peristalsis so that flatus is expelled from the intestine.

Question 16

A nurse is required to administer a cleansing enema to a 9-year-old girl. Which statement accurately describes the administration of this enema to the child?

A) Place the client in a prone position with her face down.
B) Lower the child's bed and raise both side rails.
C) Fill the enema container with the prescribed solution at 110°F.
D) Insert the rectal tube 2 to 3 in toward the umbilicus.

Question 17

How long should a client be asked to hold in the fluid introduced by a retention enema?

A) 5 to 10 minutes
B) 10 to 15 minutes
C) 15 to 25 minutes
D) 25 to 30 minutes

Question 18

The nurse is administering a tap water enema to the client. Which symptom of circulatory overload should the nurse carefully monitor the client for during and after the enema is administered?

A) Increased respiratory rate
B) Elevated blood pressure
C) Weak thread pulse
D) Decreased oxygen saturation

Question 19

The nurse is digitally removing the impacted feces of a client. What client reports or nursing observations should cause the nurse to immediately stop the procedure? Select all that apply.

A) Pain
B) Headache
C) Nausea
D) Rectal bleeding
E) Feeling faint

Question 20

The nurse is reviewing an order for a digital removal of impacted feces of a client. For which clients is digital removal of feces contraindicated? Select all that apply.

A) Respiratory conditions
B) Cardiac conditions
C) Reproductive surgery
D) Genitourinary surgery
E) Pelvic fractures

Question 21

A 40-year-old client has an episode of vomiting. On observation of the vomitus, coffee ground-like material was noticed. What is the most likely cause of this finding?

A) Forcing back of intestinal contents
B) Presence of bile pigments and salts
C) Bleeding in the lower digestive tract
D) Bleeding inside the stomach

Question 22

During episodes of vomiting, what assessment change is often observed?

A) Respirations and blood pressure increase
B) Pulse and respirations decrease
C) Respirations and temperature increase
D) Blood pressure and pulse decrease

Question 23

A 40-year-old client has an episode of vomiting. On observation of the vomitus, yellowish-green color was noticed. What is the most likely cause of this finding?

A) Forcing back of intestinal contents
B) Presence of bile pigments and salts
C) Bleeding in the lower digestive tract
D) Bleeding inside the stomach