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Saunders NCLEX-PN 7th Edition ALL Fundamentals of Care Questions &Answered (Solution guide with Rationales), Distinction Solution guide.
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Fundamentals of Care
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Saunders Comprehensive Review for the NCLEX-PN® Examination - E-Book
Saunders NCLEX-PN 7th Edition ALL Fundamentals of Care Questions &Answered (Solution guide), Distinction Solution guide.
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Saunders NCLEX-PN 7th Edition ALL Fundamentals of
Care Questions &Answered (Solution guide)
The nurse is administering a cleansing enema to a client with a fecal impaction. Before
administering the enema, the nurse asks the client to assume a left Sims' position. The nurse
explains that this positioning is preferred because of which reason?
(correct Ans)- The enema will flow into the bowel easily
Rationale:When administering an enema, the client is placed in a left Sims' position so that the
enema solution can flow by gravity in the natural direction of the colon. The anatomy of the
colon consists of ascending on the right, transverse across, with descending on the left leading to
the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into
the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax
the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain
the enema solution by administering the enema slowly. The nurse should also use teach-back to
determine client's understanding about the reason for the enema.
The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted
into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?
(correct Ans)- Advance the catheter to the bifurcation and inflate the balloon
Rationale:Urinary catheterization is a sterile procedure. When inserting an indwelling catheter,
the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated
in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse
observes the tubing for the flow of urine and then continues to advance the catheter to the point
of bifurcation and then inflates the balloon. The nurse then pulls the catheter back until slight
resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The
balloon should not be inflated when urine is first observed, after advancing several more
centimeters or when resistance is felt.
The nurse is preparing to administer an enema to an adult client. Which interventions should the
nurse plan to perform for this procedure? Select all that apply.
(correct Ans)- Apply disposable gloves.
Lubricate the enema tube and insert it approximately 4 inches.
Clamp the tubing if the client expresses discomfort during the procedure
Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C)
Rationale:The administration of an enema is a clean procedure, and standard precautions must be
used. The nurse applies disposable gloves when administering an enema to prevent the transfer
of microorganisms. To administer an enema, the nurse places the client in the left Sims' position
because the enema solution will flow downward by gravity along the natural curve of the
sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for
easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of
cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort
subsides. The container containing the enema solution is hung about 12 to 18 inches above the
,client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of
the solution should be between 100° F (37.8° C) and 105° F (40.5° C). Solution that is too hot
will burn the client, and solution that is too cool will cause cramping.
The nurse evaluates that there is a need for further teaching on bowel elimination when the client
makes which statement?
(correct Ans)- "I need to decrease fiber in my diet."
Rationale:Adequate dietary fiber is an important factor for improving bowel function. Dietary
fiber increases fecal weight and water content and accelerates the transit of the fecal mass
through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften
stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.
An older client complains of chronic constipation. Which instructions should the nurse reinforce
with the client? Select all that apply.
(correct Ans)- Increase fluids to at least eight glasses a day.
Respond in a timely manner to the urge to defecate.
Rationale:Increase of fluid intake and dietary fiber will help change the consistency of the stool
and make it easier for the client to pass. Clients should respond to the feeling of peristalsis
involved with urge to defecate. Some older clients with mobility issues may not respond to the
urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free
products and potassium in the diet will not be beneficial to the client.
The client is to receive a soapsuds enema. Which is the best position for administering an
enema? Refer to figure. (correct Ans)- A
Rationale:The Sims, or left lateral position, is the position of choice for enema administration
facilitating fluid to pass farther in the intestine. Many clients cannot tolerate the prone position.
The lithotomy position is impractical for the procedure, and knee chest is too uncomfortable.
A client receiving iron supplements is complaining of constipation and the stool that is passed is
black. Which information is appropriate for the nurse to share with the client? Select all that
apply.
(correct Ans)- Increase your fluid intake
Include more fiber in your diet
Ferrous sulfate changes the color of stool to black
Iron slows colonic acid and often leads to constipation
Rationale:As motility slows, feces are exposed to the intestinal walls and water is absorbed.
Increasing fluid intake will help by adding more fluid to the intestinal contents. Fiber increases
motility. Iron and several other medications slow motility. Lack of exercise or bed rest
contributes to constipation. An enema should not be used every other day, usually no more
frequently than on the third day. Many people do not have bowel movements every day.
Constipation is not having a bowel movement in 3 days.
, A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing
actions for the nurse to complete this task? Select all that apply.
(correct Ans)- Have the client void and then perform the bladder scan
If residual urine is less than 100 mL, continue to monitor
Rationale:To obtain a residual urine, it is necessary for the client to void, then obtain a bladder
scan. If less than 100 mL of urine (or the specific amount prescribed) is viewed on the scan,
continuing to monitor as prescribed is appropriate. Obtaining the scan before voiding would tell
the nurse how much fluid the bladder can hold. Decreasing fluids may lead to dehydration and
will not affect residual urine. Notifying the primary health care provider of normal findings is
inappropriate, as is catheterizing for 100 mL of residual urine.
After having a transurethral resection of the prostate (TURP), a client has a continuous bladder
irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none
appears to be draining. Select the appropriate nursing interventions. Select all that apply.
(correct Ans)- Check the bladder for distention
Review intake and output record
Check to ensure drainage tubing is not kinked
Ask the client about bladder spasms and discomfort
Rationale:A continuous bladder irrigation is often prescribed after a TURP to prevent blood clot
formation that will obstruct the catheter. A drainage tube that is kinked will not allow the bladder
irrigation solution to exit the body and can be done quickly while observing the system setup.
Assessing the bladder for distention would follow because a clot may be preventing drainage.
Asking the client if there is any discomfort or spasms may indicate improper drainage.
Reviewing the intake and output record is done because the nurse can see that fluid is entering
the system but not leaving. Raising the drainage bag will cause the urine to backflow into the
bladder or stop flow. Deflating the balloon and advancing the catheter should not be done
because this will introduce bacteria into the system.
Which factors contribute to the problem of stress incontinence? Select all that apply.
(correct Ans)- Obesity
Sneezing
Rationale:Obesity contributes to stress incontinence by causing increased intra-abdominal
pressure. Sneezing or laughing also often cause leakage of urine due to sudden increased intra-
abdominal pressure. Nulliparity refers to never having given birth and is not a factor of stress
incontinence; rather, a history of having three or more vaginal births is associated with stress
incontinence due to the weakening of the pelvic floor muscles. Performing Kegel exercises is
actually a means of strengthening muscle tone. Voiding at frequent intervals, such as every 2
hours decreases the volume of urine in the bladder, thus decreasing the stretch and pressure in
the bladder, and lessening the chance of incontinence.
The nurse should recognize that which type of enema has the highest risk of water intoxication?
(correct Ans)- Tap water
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