Elimination Saunders.pdf

Elimination Saunders Practice Questions 1. The nurse is assessing a client with bladder cancer who had a cystectomy and creation of a ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. “I change my pouch every week.” 2. “I change the applia...

Elimination Saunders Practice Questions 1. The nurse is assessing a client with bladder cancer who had a cystectomy and creation of a ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care? 1. “I change my pouch every week.” 2. “I change the appliance in the morning.” 3. “I empty the urinary collection bag when it is two-thirds full.” 4. “When I’m in the shower, I direct the flow of water away from my stoma.” 2. The nurse is providing care for a client with ulcerative colitis who underwent the creation of a transverse colostomy. Which observation requires immediate notification of the surgeon? 1. Stoma is beefy red and shiny. 2. Stoma has a purple discoloration. 3. Skin excoriation is noted around the stoma. 4. Semiformed stool is noted in the ostomy pouch. 3. A client with ulcerative colitis had a new colostomy created 2 days earlier and is beginning to pass malodorous flatus from the stoma. What is the correct interpretation by the nurse? 1. This is a normal, expected event. 2. The client is experiencing early signs of ischemic bowel. 3. The client should not have the nasogastric tube removed. 4. This indicates inadequate preoperative bowel preparation. 4. A client with Crohn’s disease has just had surgery to create an ileostomy. The nurse assesses the client in the postoperative period for which most frequent complication of this type of surgery? 1. Folate deficiency 2. Malabsorption of fat 3. Intestinal obstruction 4. Fluid and electrolyte imbalance 5. The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching? 1. Cleans the catheter proximally to distally with soap and water 2. Maintains the urinary collection bag below the level of the bladder 3. Removes a loose catheter anchor and places a new anchor on the lower leg 4. Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position 6. The nurse is inserting an indwelling urinary catheter in a client. As the nurse begins to inflate the balloon, the client starts to complain of pain. Which action would the nurse take? 1. Continue to inflate the balloon. 2. Deflate the balloon, slightly withdraw the catheter, and attempt to reinflate the balloon. 3. Deflate the balloon, completely withdraw the catheter, and end the procedure to notify the primary health care provider. 4. Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon. 7. The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain? 1. A straight catheter 2. A Coudé tip catheter 3. A triple-lumen catheter 4. A double-lumen catheter 8. A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? 1. Prone position 2. Lithotomy position 3. Left lateral side-lying position 4. Right lateral side-lying position 9. The nurse is preparing to irrigate a client’s sigmoid colostomy. The nurse would plan for which intervention to perform this procedure? 1. Instilling 500 to 1000 mL of lukewarm tap water through the stoma 2. Advising the client to hold the breath if cramping occurs during instillation of the solution 3. Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client’s torso 4. Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamping the tubing to allow the solution to flow into the stoma 10. The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicates an understanding of the procedure? 1. “The stoma needs to be cleaned with only water.” 2. “The best time to change the appliance is at night.” 3. “The pouch needs to be changed every 5 to 7 days.” 4. “I’ll cut the skin barrier 10 millimeters larger than the stoma.” Answers 1. Answer: 3 Rationale: The urinary collection bag needs to be changed when it is one-third full to prevent pulling of the appliance and leakage. The remaining options identify correct statements about the care of a urinary stoma. Test-Taking Strategy: Note the strategic words, need for more education. These words indicate a negative event query and the need to select the incorrect client statement. Therefore, eliminate the options that indicate client understanding. Noting the words two-thirds full will assist in directing you to the correct option. Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Evaluate Outcomes Content Area: Adult Health: Oncology Health Problem: Adult Health: Cancer: Bladder and Kidney Priority Concepts: Patient Education; Elimination Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. p. 398. 2. Answer: 2 Rationale: Ischemia of the stoma would be associated with a dusky or bluish or purple color. A beefy red and shiny stoma is normal and expected. Skin excoriation needs to be addressed and treated but does not require as immediate attention as purple discoloration of the stoma. Semiformed stool is a normal finding. Test-Taking Strategy: Note the strategic word, immediate, and focus on the subject, the observation that requires surgeon notification. Note the words purple discoloration in option 2. Recall that purple indicates ischemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Assessment Clinical Judgment/Cognitive Skill: Recognize Cues Content Area: Adult Health: Gastrointestinal Health Problem: Adult Health: Gastrointestinal: Inflammatory Bowel Disease Priority Concepts: Clinical Judgment; Tissue Integrity Reference: Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. (2021). Medical-surgical nursing: Concepts for interprofessional collaborative care. (10th ed.). St. Louis: Elsevier. p. 1121. 3. Answer: 1 Rationale: As peristalsis returns following creation of a colostomy, the client begins to pass malodorous flatus. This indicates returning bowel function and is an expected event. Within 72 hours of surgery, the client should begin passing stool via the colostomy. Options 2, 3, and 4 are incorrect interpretations. Test-Taking Strategy: Focus on the subject, that the client is passing flatus from the stoma. Think about the normal functioning of the gastrointestinal tract and note the time frame in the question to assist in answering correctly. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Clinical Judgment/Cognitive Skill: Analyze Cues Content Area: Adult Health: Gastrointestinal Health Problem: Adult Health: Gastrointestinal: Inflammatory Bowel Disease Priority Concepts: Clinical Judgment; Elimination Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. p. 954. 4. Answer: 4 Rationale: A frequent complication that occurs following ileostomy is fluid and electrolyte imbalance. The client requires constant monitoring of intake and output so that measures can be implemented to prevent this from occurring. Losses require replacement by intravenous infusion until the client can tolerate a diet orally. Intestinal obstruction is a less frequent complication. Fat malabsorption and folate deficiency are complications that could occur later in the postoperative period. Test-Taking Strategy: Note the strategic word, most. Also note the subject, an ileostomy. Remember that ileostomy drainage is liquid, placing the client at risk for fluid and electrolyte imbalance. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process—Analysis Clinical Judgment/Cognitive Skill: Prioritize Hypotheses Content Area: Adult Health: Gastrointestinal Health Problem: Adult Health: Gastrointestinal: Inflammatory Bowel Disease Priority Concepts: Clinical Judgment; Elimination Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. p. 956. 5. Answer: 3 Rationale: Routine catheter care is imperative in the prevention of catheter-associated urinary tract infections (CAUTIs). Meticulous technique needs to be used to prevent the introduction of microorganisms to the urinary tract. For uncircumcised persons, the nurse would retract the foreskin to inspect the urethral meatus for skin irritation and then cleanse the site with warm, soapy water and return the foreskin to its normal position. The catheter tubing needs to be cleaned in a proximal to distal direction. The urinary drainage bag needs to be maintained below the level of the bladder to prevent reflux of urine into the urinary tract. Any loose anchors need to be removed and replaced to ensure that the catheter tubing does not get pulled on, as this could cause trauma to the urethra. However, the anchor needs to be placed on the upper thigh, not the lower leg. Therefore, option 3 is the action that requires a need for further teaching. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect action. Visualize and think about the components of indwelling urinary catheter care in order to eliminate the correct actions and identify the action that requires further teaching. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Evaluate Outcomes Content Area: Skills: Elimination Health Problem: N/A Priority Concepts: Elimination; Safety Reference: Potter, P., Perry, A.G., Stockert, P.A., & Hall, A.M. (2021). Fundamentals of nursing. (10th ed.). St. Louis: Elsevier. p. 1190. 6. Answer: 4 Rationale: The client’s pain during inflation of the balloon may be related to the urinary catheter tip being located in the urethra and not the bladder. If the client begins to complain of pain with the inflation of an indwelling urinary catheter balloon, the nurse would allow the fluid injected into the balloon to drain back into the syringe attached to the balloon inflation port. Then, the nurse would advance the catheter farther into the urethra to the bladder, and then attempt to inflate the balloon. Therefore, option 4 is correct. Test-Taking Strategy: Focus on the subject, the procedure for indwelling urinary catheter insertion. Focus on the data in the question, and note that the client complains of pain during balloon inflation. Think about the anatomy of the urinary tract and what this client complaint could mean. Visualize the procedure in order to ascertain between expected and unexpected findings during the procedure and the appropriate actions to take. Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Clinical Judgment/Cognitive Skill: Take Action Content Area: Skills: Elimination Health Problem: N/A Priority Concepts: Clinical Judgment; Safety Reference: Potter, P., Perry, A.G., Stockert, P.A., & Hall, A.M. (2021). Fundamentals of nursing. (10th ed.). St. Louis: Elsevier. p. 1187. 7. Answer: 3 Rationale: Straight catheters are used for intermittent catheterization. Double-lumen catheters are used for indwelling urinary catheterization in which one lumen drains urine in the bladder and the other lumen is used to inflate and deflate the balloon. Triple-lumen catheters are used for continuous bladder irrigation or bladder medication instillation. One lumen is to inflate and deflate the balloon, another lumen is to drain urine and the irrigation solution, and the other lumen instills the irrigation solution into the bladder. A Coudé tip catheter is a catheter with a curved tip at the end that is used to advance the catheter past a hypertrophied prostate, in which using a standard catheter would be difficult. Therefore, option 3 is correct. Test-Taking Strategy: Focus on the subject, the urinary catheter used for continuous bladder irrigation. Visualize the procedure for continuous bladder irrigation. Remember that a triple-lumen catheter is necessary to allow balloon inflation, irrigation solution instillation, and urinary and irrigation solution drainage. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Clinical Judgment/Cognitive Skill: Generate Solutions Content Area: Skills: Elimination Health Problem: N/A Priority Concepts: Clinical Judgment; Elimination Reference: Potter, P., Perry, A.G., Stockert, P.A., & Hall, A.M. (2021). Fundamentals of nursing. (10th ed.). St. Louis: Elsevier. p. 1168. 8. Answer: 3 Rationale: For digital removal of stool, the client would be placed in the left lateral side-lying position, as this position follows the anatomical curvature of the colon. Options 1, 2, and 4 are inappropriate positions for this procedure. Test-Taking Strategy: Focus on the subject, the correct position for performing digital removal of stool. Remember that for this procedure and most procedures involving manipulation of the rectum and sigmoid colon, the left lateral side-lying position is ideal as it follows the normal curvature of the bowel. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Implementation Clinical Judgment/Cognitive Skill: Take Action Content Area: Skills: Elimination Health Problem: N/A Priority Concepts: Elimination; Safety Reference: Potter, P., Perry, A.G., Stockert, P.A., & Hall, A.M. (2021). Fundamentals of nursing. (10th ed.). St. Louis: Elsevier. p. 1215. 9. Answer: 1 Rationale: Clients with sigmoid colostomies may require irrigation of the stoma to promote regular colon emptying. Irrigation is performed by instilling 500 to 1000 mL of lukewarm tap water through the stoma and then allowing the irrigation solution and stool to drain into a collection bag. The nurse hangs the irrigation solution so that the bottom of the bag is level with the client’s shoulder. The nurse inserts the irrigation tube without force into the stoma and unclamps the tubing to allow the solution to flow into the stoma. The nurse would clamp the tubing if cramping occurs and then resume the instillation as tolerated. Test-Taking Strategy: Focus on the subject, irrigation of a sigmoid colostomy. Visualize this procedure to assist in answering correctly. Eliminate option 3 because of the words “18 inches above.” Next eliminate option 4 because the nurse should not “force” tube insertion. To select from the remaining options, eliminate option 2 because of the words “hold the breath.” The client should be encouraged to take slow, deep breaths if cramping occurs. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Clinical Judgment/Cognitive Skill: Generate Solutions Content Area: Skills: Elimination Health Problem: N/A Priority Concepts: Elimination; Safety References: Lewis, S., Harding, M., Kwong, J., Roberts, D., Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. Louis: Elsevier. p. 956; Potter, P., Perry, A.G., Stockert, P.A., & Hall, A.M. (2021). Fundamentals of nursing. (10th ed.). St. Louis: Elsevier. p. 1216. 10. Answer: 3 Rationale: Clients with urinary diversions need to be educated on the proper care of the urinary stoma. An appliance with an attached collection bag is placed over the stoma to collect urine. The most ideal time to change the appliance is in the morning, not at night. The stoma needs to be cleaned with both nonresidue soap and water, not just water. The skin barrier needs to be cut no more than 3 millimeters larger than the stoma to prevent urine leakage and irritation of the exposed skin. The pouch needs to be changed every 5 to 7 days. Therefore, option 3 indicates client understanding of the procedure. Test-Taking Strategy: Focus on the subject, care of a urinary diversion or stoma. Visualize a urinary stoma and think about the goals of care. Next, consider the actions in each of the options to answer correctly. This will assist in answering correctly. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Evaluate Outcomes Content Area: Skills: Elimination Health Problem: N/A Priority Concepts: Patient Education; Elimination Reference: Potter, P., Perry, A.G., Stockert, P.A., & Hall, A.M. (2021). Fundamen