Deck 55: Elimination

Question 1

The nurse plans to assist in the transfer of the client to a bedside commode. Place the procedure steps in the correct order.

A)Place slippers on the client.
B)Place commode at the foot of the bed.
C)Raise the client's head of the bed and move client to the edge of the bed.
D)Safely transfer the client to the commode.
E)Cover client with bath blanket as needed for warmth.

Answer 1

Place slippers on the client.
Place commode at the foot of the bed.
Raise the client's head of the bed and move client to the edge of the bed.
Safely transfer the client to the commode.
Cover client with bath blanket as needed for warmth.

Question 2

When placing the client on a bedpan, which position will the nurse place the client?

A)High-Fowler's
B)Semi-Fowler's
C)Upright
D)Supine

Answer 2

Semi-Fowler's

Question 3

A nurse attempts to obtain a urine sample from a client's ileal conduit. After correct sterile catheterization, no urine output is noted. How should the nurse respond?

A)Contact the health care provider.
B)Reinsert the catheter.
C)Ask the client to drink water.
D)Advance the catheter further in the stoma.

Answer 3

Ask the client to drink water.

Question 4

The home care nurse prepares to drain the fluid of a client with continuous ambulatory peritoneal dialysis (CAPD). Place the steps in correct order of the procedure to drain the fluid.

A)Attach the sterile bag and transfer set to the catheter.
B)Place the bag on a low stool or table below the client's abdomen.
C)Unclamp the tubing and allow fluid to drain.
D)Reclamp the tubing.
E)Don gloves and uncap the catheter.

Question 5

A nurse prepares to administer a warm water enema to a client. Place the steps of the procedure in correct order.

A)Raise the solution container.
B)Open the clamp.
C)Encourage the client to retain the solution.
D)Lift the upper buttock, insert the tube slowly.
E) Assist the client to the left lateral position with right leg flexed.
F)Allow the solution to run through the tubing to remove air.

Question 6

When auscultating a client's AV fistula, the nurse notes a whooshing sound. What term is used to describe this finding?

A)Bruit
B)Murmur
C)Gallop
D)Click

Question 7

The nurse prepares to obtain a urine specimen from a client's indwelling catheter. What is the nurse's understanding of the purpose of clamping the indwelling catheter prior to collection of urine?

A)Decreases client discomfort.
B)Increases urine production.
C)Promotes sterile collection.
D)Eases technique of procedure.

Question 8

When assessing the client's AV fistula, the nurse notes vibration at the fistula site. How should the nurse respond to this finding?

A)Contact the health care provider.
B)Ask the client how long this has occurred.
C)Determine when the fistula was placed.
D)Document the finding.

Question 9

The nurse cares for a client who requires hemodialysis and has an arteriovenous fistula. Which statements will the nurse include when teaching the client safety precautions for the AV fistula? Select all that apply.

A)"Keep the AV fistula dry and avoid washing with soap."
B)"Do not wear constrictive clothing or jewelry."
C)"Avoid lifting heaving objects with the extremity that has the AV fistula."
D)"Avoid lying on the extremity with the AV fistula."
E)"Immediately report swelling or discoloration."

Question 10

The nurse cares for a client with an AV fistula for hemodialysis. Which assessments will the nurse perform when assessing the AV fistula? Select all that apply.

A)Palpation
B)Auscultation
C)Inspection
D)Percussion

Question 11

The nurse is planning care for a client who receives peritoneal dialysis. Which nursing diagnosis will the nurse determine is priority?

A)Knowledge deficit
B)Risk for infection
C)Impaired skin integrity
D)Fluid volume excess

Question 12

The nurse prepares to remove a client's indwelling urinary catheter. Which technique will the nurse use when performing this procedure? Select all that apply.

A)Aspirate the balloon vigorously.
B)Withdraw all the fluid from the balloon.
C)Detach the catheter from the client's skin.
D)Use clean gloves instead of sterile gloves.
E)Place a towel between the client's legs.

Question 13

The nurse prepares to perform an indwelling urinary catheterization for a client who will undergo surgery. Place the steps of client positioning and sterile glove donning in the correct order.

A)Open the drainage package, maintaining sterility.
B)Position the client.
C)Remove and discard gloves; perform hand hygiene.
D)Open the catheterization kit; apply sterile gloves.

Question 14

The nurse teaches a client with a peritoneal dialysis catheter about the signs and symptoms of peritonitis. Which teaching statements will the nurse include? Select all that apply.

A)"Monitor your temperature and report any fever."
B)"Monitor your urine output and report any decrease in output."
C)"Report any nausea or vomiting you may have."
D)"Monitor the insertion site and report any redness."
E)"Report any abdominal pain you may have."

Question 15

The nurse prepares to change a client's fecal ostomy pouch. Which assessments regarding the stoma are priority? Select all that apply.

A)Skin around the stoma.
B)Location of the stoma.
C)Appearance of the stoma.
D)Date of stoma placement.
E)Complications during placement of stoma.

Question 16

The nurse prepares to obtain a urine sample from a client's closed drainage system. Place the procedure steps in the correct order.

A)Disinfect the needle insertion site.
B)Insert the needle at a 30-to 40-degree angle.
C)Unclamp the catheter.
D)Transfer the urine to the specimen container.
E)Withdraw the required amount of urine.
F)Clamp the drainage tubing at least 8 cm (3 in.) below the sampling port for 30 minutes.

Question 17

An uncircumcised male client needs to provide a clean-catch urine sample. Which client teaching will the nurse provide the client regarding the procedure? Select all that apply.

A)Retract the foreskin slightly.
B)Pull the foreskin over the meatus.
C)Use a circular motion to clean the meatus.
D)Use each towelette only once, then discard.
E)Void a small amount prior to collecting the sample.

Question 18

The home care nurse cares for a client who requires continuous ambulatory peritoneal dialysis (CAPD)at home. Place the steps in correct order for infusing the dialysate.

A)Warm the dialysate.
B)Add medications to the dialysate as ordered.
C)Connect tubing to dialysate bag.
D)Perform hand hygiene and don gloves.
E)Hang the dialysate bag above the client's shoulder and open the clamp.

Question 19

A nurse performs a sterile urine specimen collection from an ileal conduit. Which action by the nurse is incorrect and may lead to inaccurate results?

A)Removing the collection pouch prior to obtaining the sample.
B)Inserting the tip of the catheter into the stoma approximately 4 cm (1.5 inches).
C)Obtaining the sample from the collection pouch.
D)Placing towels around the stoma.

Question 20

The registered nurse acts as preceptor to a novice nurse who is placing an indwelling urinary catheter for a client. Which action by the novice nurse requires intervention by the preceptor?

A)Removing and discarding clean gloves after opening the drainage package.
B)Cleansing the urethral meatus before removing the catheter from the protective sleeve.
C)Donning sterile gloves prior to attaching the catheter to the drainage system.
D)Lubricating the tip of the catheter before inserting the tip of the prefilled syringe into the catheter side arm.