Find study materials for any course. Check these out:
Browse by school
Make your own
To login with Google, please enable popups
To login with Google, please enable popups
Don’t have an account?
To signup with Google, please enable popups
To signup with Google, please enable popups
Sign up withor
A school nurse is planning a health class about bodily functions. What information should be included regarding the purpose of mucus in the GI tract?
1. activates digestive enzymes
2. protects gastric mucosa
3. enhances gastric acidity
4. emulsifies fats
2. mucus protects body surfaces from friction and erosion
presence of fluid or food activates digestive enzymes. does not enhance gastric acidity, and low surface tension of fats of bile salts contributes to emulsification of fats in intestine
A patient complains of constipation. What should the nurse encourage the patient to eat?
A patient is experiencing constipation. Which independent nursing action facilitates defecation of hard stool?
1. applying lubricant to the anus
2. encouraging a sitz bath after defecation
3. instilling warm mineral oil into rectum
4. positioning cold compress against the anus
1. a lubricant reduces friction, which facilitates passage of hard, dry stool.
A sitz bath requires a practitioners order and thus is not an independent action of the nurse, as does instilling a warm mineral oil. a warm compress may facilitate defecation, but a cold compress will not.
A nurse is caring for a patient with a nasogastric tube attached to suction. What is the most important nursing action in relation to the nasogastric tube?
1. using sterile technique when irrigating the tube
2. recording intake an output every 2 hours
3. maintaining suction at the prescribed level
4. providing oral hygiene every 4 hours.
maintaining suction at the prescribed level. (low suction is 80 -100 and high suction is 100-120.
oral hygiene should be provided more frequently than every 4 hours. I&O does not need to be recorded this frequently. Medical, not surgical asepsis is necessary.
which action is most important for the nurse to teach patients about the intake o bran to facilitate defecation.
1. eat 3 tablespoons each morning
2. drink at least 8 glasses of fluids each day
3. have a bowel movement right after ingesting the bran
4. take a cathartic that will supplement the action of the bran
2. drink at least 8 glasses of water each day.
3 tbspns is too much, a bowel movement right after is too soon, and a cathartic will weaken the bowels natural response to fecal distention
a nurse identifies that a patients colostomy stoma is pale. what should the nurse do?
1. notify the practitioner
2. listen for bowel sounds
3. wash the area with warm water
4. gently massage around stoma
1. a pale stoma indicates that the circulation to the stomal is compromised and viability of tissue is questionable without immediate intervention.
listening for bowel sounds might be done but is not priority. washing with warm water is inappropriate and a waste of time and massaging may injure surrounding tissue.
a nurse identifies that a patient understands the need to reestablish bowel flora after a week of diarrhea when the patient states, "I'm going to..."
1. wean myself off antibiotics one day after my temperature is normal
2. eat a container of yogurt every day for a few days
3. add rice to diet one meal each day
4. drink eight glasses of water each day
2. eating yogurt helps to restore the bacterial balance of resident flora of the intestine.
water is essential for all body processes and to replace fluid lost in diarrhea but it does not reestablish bowel flora
a patient is reporting burning on urination. which question should the nurse ask to best obtain information about the patients dysuria?
1. can you tell me about the problems you've been having with urination
2. how would you describe your experience with incontinence?
3. what are your usual bowel habits?
4. what color is your urine?
a nurse is caring for a group of patients with a variety of urinary problems. which patient response should cause the most concern?
anuria. inability to produce urine is a life-threatening situation.
dysuria= difficulty urinating
diuresis=secretion and excretion of large amounts of urine
enuresis=involuntary discharge or urine after an age when bowel control should be
a nurse has identified that the patient has overflow incontinence. what is a major factor that contributes to this clinical manifestation?
2. mobility deficits
3. prostate enlargement
4. urinary tract infection
coughing is related to stress incontinence. mobility deficits are related to reflex incontinence. urinary tract infections are related to urge incontinence.
which piece of equipment is most appropriate for measuring urine output from a urinary retention catheter?
3. large syringe
4. urine collection bag
a nurse is caring for a debilitated female patient with nocturia. which nursing intervention is the priority when planning to meet this patients needs?
1. encouraging use of bladder training exercises
2. providing assistance with toileting every 4 hrs
3. positioning bedside commode near bed
4. teaching avoidance of fluids after 5pm
position bedside commode near bed.
bladder training exercises should be done but not a priority. every 4 hrs may be too often or not often enough, and avoidance of fluids completely after 5pm is not recommended.
a nurse Is caring for a patient with a condom catheter. which nursing diagnosis is most important
1. providing perineal care every shift
2. avoiding kinks in the collection tubing
3. ensuring Velcro strap is snug, not tight
4. retracting foreskin before catheter is applied.
what should the nurse teach the patient to avoid to prevent urinary diuresis
a nurse is caring for two patients, one with reflex incontinence and another with total incontinence. which characteristic is common to both?
1. urination following an increase in intra-abdominal pressure
2. loss of urine without awareness of bladder fullness
3. retention of urine with overflow incontinence
4. strong, sudden desire to void
boys may take longer than girls.
Children in North American cultures usually achieve daytime urinary continence by 3 years of age; Nighttime continence may not occur until 4 or 5 years of age.
what is the most significant change in kidney function that occurs with aging?
1. decreased glomerular filtration rate
2. proliferation of micro blood vessels to renal cortex
3. formation of urate crystals
4. increased renal mass
decreased glomerular filtration rate
the student nurse tells her instructor that she cannot palpate her patients bladder. which statement by the instructor is best?
1. try to palpate it again, it takes practice
2. palpate the patients bladder only when it is distended by urine.
3. document this abnormal finding on the chart
4, immediately notify the nurse
which urine specific gravity would be expected in a patient with dehydration?
Normal urine specific gravity is 1.01 to 1.025. specific gravity less than 1.010 indicates fluid volume excess and spec. gravity greater than 1.025 indicates deficient fluid volume.
The nurse is caring for a patient who underwent a bowel resection 2 hours ago. his urine output for the past 2 hrs totals 50 ml. which action should the nurse take?
1. do nothing, this is normal
2. increase infusion rate of iv fluids
3. notify provider of patients oliguria
4. administer patients routine diuretic dose early
50 ml in two hours is not normal output. kidneys typically produce 60 ml. of urine per hour. nurse cannot increase infusion rate without providers order, nor can the nurse administer meds early without an order
what position should the patient assume before the nurse inserts an indwelling urinary catheter?
1. modified trendelenburg
3. dorsal recumbent
a patient complains that she passes urine whenever she sneezes or coughs. how should the nurse document this?
2. overflow incontinence
3. urge incontinence
4. stress incontinence
which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer?
1. patient will resume his normal urination pattern by target date
2. patient will perform urostomy self-care by target date
3. patient will perform self-catheterization by target date
4. patients urine will remain clear with sufficient vol
a patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. which statement by the patient would indicate correct understanding of the procedure?
1. I will need to replace the catheter weekly
2. use clean, rather than sterile technique at home
3. remember to inflate the catheter balloon after insertion
4. I will dispose of catheter after use and get new one each time
the nurse notes that a patients indwelling catheter tubing contains sediment and crusting at the meatus. what should nurse do?
1. notify provider
2. flush catheter
3. replace catheter
4. encourage fluid intake
a patient is admitted with high BUN and creatinine levels, low blood PH, elevated serum potassium. based on lab findings the nurse suspects which diagnosis?
2. renal calculi
4. renal failure
elevated BUN, creatinine and serum potassium w low blood PH are signs of renal failure. cystitis is an infection of the bladder and would not result in abnormal renal function. renal calculi typically produce blood in urine but do not lead to marked renal dysfunction.
a patient is prescribed Lasix, a loop diuretic for treatment of congestive heart failure. the patient is at risk for which electrolyte inbalance?
what is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter?
1. use antiseptic wipes to cleanse meatus prior to voiding
2. briefly disconnect catheter from drainage tube to obtain sample
3. withdraw urine through port using needleless access device
4. obtain urine specimen directly from collection bag.
which of the following is (are) appropriate goal(s) for a patient with urinary incontinence?
1. increase intake of citrus fruits
2. increase oral fluids to 8 to 10 glasses per day
3. limit daily caffeine intake
4. engage in high-impact, aerobic exercises
True or false?
Nurses should obtain information about urinary control from all female patients?
when changing a diaper, the nurse observes that a 2 day old infant had a green black, tarry stool. what should the nurse do?
1. notify the physician
2. do nothing, this is normal
3. give the baby sterile water until the mothers milk comes in
4. apply a skin barrier cream to the buttocks to prevent irritation
based on the stage of physical development at which toilet training becomes physically possible, for which age would a goal of "achieves toilet training by the end of this month" be most appropriate?
1. 18 months
2. 2.5 years
3. 3.5 years
4. 4 years
between the ages of two and 3 children can typically control defecation. boys typically take longer.
the nurse has taught a patient about the primary risk factors for irritable bowel syndrome. which behavior by the patient would be evidence of learning?
1. reduces intake of gluten
2. eliminates intake of lactose
3. consumes only 4 cups of coffee per day
4. takes measures to reduce stress level
stress is primary factor in development of IBS. coffee and lactose are risk factors but they are not primary risk factors.
which of the following goals is appropriate for a patient with constipation?
1. milk and cheese
2. break and pasta
3. fruits and vegetables
4. lean meats
fruits and vegetables.
nurse should encourage patient to increase intake o foods rich in fiber because they promote peristalsis.
a patient is diagnosed with an intestinal infection after traveling abroad. the nurse should encourage the intake o which food to promote healing?
active bacteria in yogurt stimulate peristalsis and promote healing of intestinal infections.
the nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function in an adult
1. 2 to 4 glasses
2. 4 to 6 glasses
3. 6 to 8 glasses
4. 8 to 10 glasses
a patient w skin infection is prescribed antibiotic. patient says last time he took meds, he had frequent loose stools. what should nurse recommend?
1. stop taking drug immediately if diarrhea develops
2. take antidiarrheal agent
3. consume yogurt daily
4. increase intake of fiber until fiber stops
consume yogurt daily. antibiotics decrease the normal flora in the colon that cause diarrhea. bacterial populations can be maintained by encouraging patient to consume yogurt daily while taking the drugs. increasing fiber combats constipation, not diarrhea.
the healthcare team suspects that a patient has an intestinal infection. which action should the nurse take to help confirm the diagnosis?
1. prepare the patient for abdominal plate
2. collect stool specimen that contains 20 to 30 ml. of liquid stool
3. administer laxative to prepare patient for colonoscopy
4. test patient's stool using fecal occult test
the nurse is instructing a patient about performing home testing for fecal occult blood. the nurse should explain that ingestion of which substance may cause a false negative fecal occult blood test?
1. vitamin D
3. vitamin C
(iron can result in a false positive)
the nurse must irrigate the colostomy of a patient who is unable to move independently. how should the nurse position the patient for this procedure?
2. left side lying
3. supine w head of bed lowered flat
4. supine with head of bed raised 30 degrees
left side lying.
immobile patient should be placed in left side lying position to irrigate colostomy.
a mother of a school age child says child has diarrhea and vomiting for 24 hours but appetite has since returned. which recommendation should nurse make to mother?
1. consume diet of bananas, white rice, applesauce, and toast
2. drink large quantities of water
3. take antidiarrheal
4. increase consumption of raw fruits and vegies
which is a key treatment for a patient with diverticulitis?
the nurse assesses patients abdomen 4 days after surgery and notes bowel sounds are absent. this finding most likely suggests which postoperative complication?
1. paralytic ileus
2. small bowel obstruction
a patient with a colostomy complains to the nurse they are having really bad odors come from the pouch. what foods should the nurse advise of to help control smell.
1. white rice and toast
2. tomatoes and dried fruit
3. asparagus and melons
4. yogurt and parsley
yogurt and parsley.
white rice and toast help control diarrhea. tomatoes and fruit provide fiber that may cause blockage.
patient has a colostomy in the descending colon and wishes to control bowel evacuation and stop wearing an ostomy pouch. nurse should:
1. call primary care provider if stoma becomes pale, dusky, or black
2. limit intake of gas forming foods such as cabbage, onions and fish
3. irrigate stoma to produce bowel movement on schedule
4. avoid returning to use of ostomy appliance if ill
which factor(s) place patient at risk for constipation.
1. sedentary lifestyle
2. high dose calcium therapy
3. lactose intolerance
4. spicy food
the nurse must administer an enema to an adult patient with constipation. which of the following is a safe distance for the nurse to insert the tubing.
1. 2 inches
2. 3 inches
3. 4 inches
4. 5 inches
...and (liver disease)
what should nurse teach the patient to avoid to prevent urinary diuresis
which clinical manifestation can a nurse expect when a postoperative patient experiences stress associated with surgery?
1. decreased urinary output
2. low specific gravity
3. reflex incontinence
4. urinary hesitancy
specific gravity normal range
is patient states it burns every time they pass urine. the nurse should make inference that the patient is most likely experiencing
1. reflex incontinence
2. stress incontinence
3. retention of urine
4. an infection
burning on urination is associated with mucosal inflammation that occurs with urinary tract infections.
a patient tells the nurse they have to go to urinate as soon as they get the urge to go. for which contributing factor to urinary urgency should the nurse implement a focused assessment?
2. full bladder
4. urinary tract infection
a patient has a history or urinary tract infections. what should the nurse include in a teaching plan regarding why 8 ounces of cranberry juice daily helps to minimize occurrence of urinary tract infections.
1. dilutes bacterial growth
2. promotes acidic urine
3. prevents urinary retention
4. stimulates hypoactive detrusor muscles
promotes acidic urine.
microorganisms grow better in alkaline urine. (does not dilute bacterial growth)
what should the nurse monitor to best assess a patients renal perfusion?
1. blood pressure every 15 minutes
2. urinary output every hour
3. body weight daily
4. I&O every 24 hours
urinary output every hour.
one liter of fluid should weigh approx. 2.2 lbs. 24 hrs. is too long period of time.
a patient has a urinary retention catheter. which is most important when the nurse cares for this patient?
1. ensuring catheter remains connected to the collection bag
2. applying antimicrobial agent to urinary meatus 2 X day.
3. wearing sterile gloves
4. increasing fluid intake to 3000 ml day
a nurse is assessing a patient for the presence of dysuria. the nurse should ask, do you?
1. feel you are able to empty your bladder fully each time you void?
2. have a problem stopping or starting flow of urine
3. pass a little urine when you cough or sneeze
4. experience pain or burning on urination
4. experience pain or burning on urination.
1 - refers to urinary retention
2 - refers to person w hesitancy
3 - refers to person w stress incontinence
what clinical manifestation identified by the nurse most commonly is associated with excessive production of antidiuretic hormone
a patient is admitted to the emergency room because of hypertension and oliguria. for what additional clinical manifestation associated with this info should the nurse assess?
3. weight gain
4. urinary hesitancy
when a nurse assesses a patient, which clinical manifestations support the presence of urinary retention?
3. bladder contractions
4. suprapubic distention
5. frequent small voidings
1, 2, 5
hematuria is presence of rbc's in urine, associated w bladder inflammation not retention. urinary retention may produce an atonic bladder rather than bladder contractions.
which of the following is a true statement about the effects of medication on bowel elimination
1. diarrhea commonly occurs with amoxicillin use
2. anticoagulants cause white discoloration of stool
3. narcotics increase GI motility
4. iron salts impair digestion and cause green stool
anticoagulants cause stool to become pink/red. iron salts cause stool to become black. narcotics decrease GI motility
Mr. J has a fecal impaction. The nurse correctly administers an oil-retention enema by doing which of the following?
1. administering a large volume of solution (500-1000 ml)
2. mixing milk and molasses in equal parts for an enema.
3. instructing patient to retain enema for at least 30 minutes
4. administering enema while patient is on toilet
usual amount for retention enema is 150-200 ml.
a colonoscopy is a:
1. visual examination of esophagus and stomach
2. visual examination of large intestine
3. radiographic examination of large intestine
4. fluoroscopic exam of small intestine
2. visual exam of large intestine
barium enema = radiographic exam of large intestine
esophagogastroduodenoscopy allows visual exam of stomach and esophagus
upper gastrointestinal series - fluoroscopic exam of small intestine
nurses should recommend avoiding habitual use of laxatives. which of the following is a rationale for this?
1. the cause fecal impaction
2. they cause chronic constipation
3. they change pH of GI tract
4. they inhibit intestinal enzymes
2. they cause chronic constipation
habitual use of laxatives is the most common cause of chronic constipation
when explaining the action of a hypertonic solution enema, the nurse incorporates which of the following as the basis for action?
1. bowel mucosa irritation
2. diffusion of water out of colon
3. osmosis of water into colon
4. softening of fecal contents
3. osmosis of water into colon
hypertonic solutions draw water into the colon by osmosis, thus stimulating the defecation reflux. oil solutions soften fecal contents, and soap solutions distend the intestine and irritate the bowel mucosa.
which of the following statements concerning peristalsis is true?
1. sympathetic nervous system inhibits movement
2. peristalsis occurs every 25 - 30 mins
3. 1/2 to 3/4 of ingested food waste products normally are excreted in the stool within 24 hours.
4. mass peristaltic sweeps occur one to four times every 24 hours in most people
peristalsis occurs every 3-12 minutes.
which of the following foods has a constipating effect?
(processed foods, bananas, carrots, rice also)
which of the following is the barrier between the large intestine and the ileum of the small intestine.
1. ileocecal junction
3. splenic flexure
4. hepatic flexure
which of the following classification of medications can cause increased urination
2. central nervous system depressants
3. cholinergic agents
4. stool softeners
Sign up for free and study better.
Get started today!