NCLEX-PN Remediation
Elimination
A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A
cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. What should the nurse do?
Rationale: Palpate above the pubic symphysis A full bladder is palpable with urinary retention and distention, which are common problems after a cystoscopy because of urethral edema. Fluids dilute the urine and reduce
the chance of infection after cystoscopy and should not be limited. Although urinary retention can occur, it is not expected; the nurse must assess the extent of bladder distention and discomfort. More conservative nursing methods, such as running water or placing a warm cloth over the perineum, should be attempted to precipitate voiding; catheterization carries a risk of infection.
A nurse is obtaining a health history from the mother of a 15-month-old toddler with celiac disease. The nurse expects the mother to indicate what about her toddler?
Rationale: Has bulky, foul, frothy stools
Steatorrhea (fatty, foul-smelling, frothy, bulky stools) occurs with celiac disease because of an intolerance to gluten; toxic substances, which can damage the intestinal mucosal cells, accumulate and cause diarrhea. Drinking large amounts of fluid is a response to dehydration. With celiac disease some thirst may occur, but it is not continuous. Although infants with celiac disease are irritable, this sign is too vague for accurate evaluation. Irritability is symptomatic of a variety of problems, ranging from cutting of teeth to leukemia. Concentrated urine is associated with a urinary tract infection or dehydration; this sign is too vague to permit accurate evaluation.
A client with an ileal conduit is being prepared for discharge. As part of the discharge teaching, what does the nurse instruct the client to do?
Rationale: Maintain fluid intake of at least 2L daily
High-fluid intake flushes the ileal conduit and prevents infection and obstruction caused by mucus or uric acid crystals. Alcohol is not contraindicated with an ileal conduit. Notifying the health care provider if the stoma size decreases is expected; as edema decreases, the stoma will become smaller. Soap and water on the peristomal area help prevent irritation from waste products. A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching?
Rationale: "My incision will probably be painful" The TURP procedure is performed by insertion of a scope device into the urethra to reach
the prostate from within the urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being painful after surgery warrants further evaluating and teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake.
A health care provider prescribes bisacodyl (Dulcolax) for a client with cardiac disease. The nurse explains to the client that this drug acts by doing what?
Rationale: Stimulating peristalsis
Bisacodyl stimulates nerve endings in the intestinal mucosa, precipitating a bowel movement. Bisacodyl is not a bulk cathartic. Bulk-forming laxatives, such as psyllium hydrophilic mucilloid (Metamucil), form soft, pliant bulk that promotes physiological peristalsis. Bisacodyl is not a stool softener. Stool softeners, such as docusate sodium, permit fat and water to penetrate feces, which softens and delays the drying of the feces. Bisacodyl is not an emollient. Emollient laxatives, such as mineral oil (Kondremul), lubricate the feces and decrease absorption of water from the intestinal tract.
A male client with a brain attack (cerebrovascular accident) has regained control of bowel movements but still is incontinent of urine. To help reestablish bladder control, the nurse should encourage the client to do what?
Rationale: Assume a standing position for voiding
Assuming a standing position for voiding reduces tension (physical and psychological), facilitates the movement of urine into the lower portion of the bladder, and relaxes the external sphincter (increasing pressure and initiating the micturition reflex). Bladder training should be instituted by encouraging voiding everyone to two hours and progressively increasing the time between attempts. Voiding should be encouraged at regular and frequent intervals during waking hours, not just in the afternoon. Four liters is
a large fluid intake and is unnecessary; it will result in a large volume of urine, probably increasing the frequency of incontinence. A nurse is caring for a client with a T-tube after an open cholecystectomy. What specificaction should the nurse include in the plan of care?
Rationale: Monitor the color of the stool
A T-tube maintains patency of the common bile duct until inflammation subsides; when the duct is patent and bile enters the gastrointestinal tract, the color of stool is brown. Ankle pumping prevents venous stasis if a client is not able to ambulate. Absence of bile affects the ability to digest fats, not carbohydrates. A T-tube drains by gravity; it is not a self-contained suction device like a Hemovac, so compression is not necessary.
A four-year-old child with a new colostomy is to be discharged in several days. What should the nurse teach the parents about their child's home care?
Rationale: Encouraging physical activity
Contact games may be restricted, but other physical activities should be encouraged. The stoma should be inspected more often than once daily to ensure adequate circulation. Increased fluid intake is needed to compensate for fecal fluid loss. The diet should not be restricted at the time of discharge. Both the parents and the child will learn which foods are poorly tolerated, and they will adjust the diet accordingly. A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply.
Rationale: Cool skin, constipation, periorbital edema, and decreased appetite
Cool skin is related to the decreased metabolic rate associated with insufficient thyroid hormone. Constipation results from a decrease in peristalsis related to the reduction in the
metabolic rate associated with hypothyroidism. Periorbital and facial edema are caused by changes that cause myxedema and third-space fluid effusion seen in hypothyroidism. Decreased appetite is related to metabolic and gastrointestinal manifestations of the hypothyroidism. A client is scheduled for ligation of hemorrhoids. Which diet does the nurse expect to be prescribed in preparation for this surgery?
Rationale: Low-residue
A low-residue diet limits stool formation. Bland diets usually are employed in the management of upper, not lower, gastrointestinal disturbances. Although a clear diet is low in residue, it does not meet nutritional needs. A high-protein diet is indicated postoperatively to promote healing. A client who had a transurethral resection of the prostate is transferred to the postanesthesia care unit with an intravenous (IV) line and a urinary retention catheter. For which major complication is it most important for the nurse to assess during the immediate postoperative period?
Rationale: Hemorrhage
After transurethral surgery, hemorrhage is common because of venous oozing and bleeding from many small arteries in the area. Following transurethral surgery, sepsis is unusual, and if it occurs, it will manifest later in the postoperative course; phlebitis is assessed for, but it is not the most important complication; and leaking around the IV catheter is not a major complication. A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. What should this should be documented in the medical record as?
Rationale: Overflow incontinence Overflow incontinence describes what is happening with this client; overflow incontinence occurs with retention of urine with overflow of urine. Urge incontinence describes a strong need to void that leads to involuntary urination. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal
pressure that occurs with coughing, lifting, or sneezing. Reflex incontinence is an involuntary loss of urine at fairly predictable intervals when certain urinary bladder intervals are reached.
After an abdominal hysterectomy the client returns to the unit with an indwelling catheter. The nurse notes that the urine in the client's collection bag has become increasingly sanguineous. What complication does the nurse suspect?
Rationale: An incisional nick in the bladder
During an abdominal hysterectomy the urinary bladder may be nicked accidentally. The client is not likely to have an infection with bleeding so soon. Bleeding would be present from other sites, such as the incision, as well as in the urine bag. The uterus is removed with a hysterectomy; therefore there is no uterine bleeding
