Question 1

What is the name of the given device used for collecting waste from a stoma?

Accepted Answer

Answer reason: An ostomy collection bag is specifically designed to collect fecal or urinary waste from a surgically created stoma. It attaches securely to the skin barrier and provides continuous waste collection.

Question 2

What is the primary purpose of administering a saline enema to a patient?

Accepted Answer

Answer reason: A saline enema is isotonic and works by softening the stool and stimulating peristalsis, facilitating bowel evacuation. It is not intended for systemic hydration or medication delivery.

Question 3

Which of the following is a correct nursing action when collecting a urine specimen from a client with an indwelling catheter?

Accepted Answer

Answer reason: To obtain a sterile specimen from an indwelling catheter, clamp below the sampling port, disinfect the port, and use a sterile syringe to aspirate urine from the sampling port. Do not collect from the drainage bag or disconnect the tubing, which increases contamination risk.

Question 4

The nurse is caring for a homebound client who has a urinary catheter. The client's husband says he thinks the catheter is obstructed. Which of the following observations would confirm this suspicion?

Accepted Answer

Answer reason: Bladder distention is an objective sign of urinary retention from catheter blockage. The urge to void and burning suggest irritation or a UTI, and concentrated urine indicates dehydration rather than obstruction.

Question 5

Which of the following is not a purpose of catheterization of the urinary bladder?

Accepted Answer

Answer reason: Urinary catheterization is used for diagnostic purposes, to relieve urinary retention, and, perioperatively, to keep the bladder empty. Colostomy irrigation is a bowel procedure unrelated to the urinary bladder.

Question 6

What is the appropriate volume of solution for an infant enema?

Accepted Answer

Answer reason: Infants require small enema volumes to prevent bowel distension and fluid–electrolyte imbalance; the typical recommended volume is about 100–200 mL.

Question 7

When giving an evacuant enema to children, the amount of solution for children should be used?

Accepted Answer

Answer reason: Standard cleansing (evacuant) enema volumes: infants ~100–200 mL, children ~250–500 mL, adults ~500–1000 mL. Therefore, the appropriate amount for children is 250–500 mL.

Question 8

The nurse is caring for a postpartum client two hours post-delivery who is unable to void. Which of the following nursing interventions should be considered initially?

Accepted Answer

Answer reason: The initial nursing action is to assess. Palpating the bladder determines urinary retention and guides the next steps; other options are interventions after confirming the problem.

Question 9

The nurse is assessing a client who has a new ureterostomy. Which statement by the client indicates the need for more education about urinary stoma care?

Accepted Answer

Answer reason: Urostomy pouches should be emptied when one-third to one-half full to prevent weight pulling the seal loose and leakage; waiting until two-thirds full indicates inadequate education. The other statements are acceptable care practices.

Question 10

Which of the following intervention is not recommended in watery diarrhea?

Accepted Answer

Answer reason: Management of watery diarrhea focuses on rehydration and electrolyte replacement (e.g., normal saline, potassium) and may include soluble fiber like psyllium to bulk stools. Intravenous albumin is not indicated for diarrhea treatment and offers no benefit.

Question 11

A 53yr old woman becomes symptomatic as a result of a cystocele. If the cystocele is not severe, which suggestion by the nurse can best aid the client s incontinence?

Accepted Answer

Answer reason: Pelvic floor (Kegel) exercises strengthen perineal muscles and are first-line conservative management for stress incontinence from a mild cystocele. Other options do not address the cause or may be inappropriate.

Question 12

The nurse is to administer a cleansing enema to a client scheduled for colon surgery. Which client position would be appropriate?

Accepted Answer

Answer reason: Left Sims' positions the client on the left side with right knee flexed, aligning the rectum and sigmoid colon for optimal enema flow and retention. Other positions do not facilitate effective enema administration.

Question 13

A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?

Accepted Answer

Answer reason: Ileostomy effluent is liquid and enzyme-rich, which can quickly irritate and damage skin; meticulous peristomal skin care is essential. Massaging the stoma is not indicated, high-fiber foods like nuts can cause blockage, and fluid intake should be increased—not restricted.

Question 14

The nurse is assessing a client with an indwelling catheter and finds the catheter is not draining and the client's bladder is distended. What is the nurse's first best action?

Accepted Answer

Answer reason: First correct nursing action is to troubleshoot mechanical causes of poor drainage by checking for kinks and ensuring the collection bag is below the bladder before escalating or replacing the catheter.

Question 15

Length to which rectal catheter need to be inserted while giving enema is ..........?

Accepted Answer

Answer reason: For adult enema administration, the rectal catheter is inserted about 7.5–10 cm (3–4 inches). Among the choices, 10 cm is correct and safe.

Question 16

What is the priority nursing action when a patient has voided only 50-100 ml of urine after removal of a Foley catheter?

Accepted Answer

Answer reason: After catheter removal, small voids can indicate urinary retention. The priority is to assess for bladder distention (e.g., palpation/bladder scan) before interventions like fluids or recatheterization.

Question 17

Which action should the nurse avoid when administering a soap suds enema?

Accepted Answer

Answer reason: For a soap suds enema, add a small amount of mild (e.g., castile) soap to warm water and mix gently. Injecting suds (foam) directly introduces air into the system, causing discomfort and cramping. The other actions are appropriate.

Question 18

A client in her third trimester tells the nurse, 'I'm constipated all the time!' Which of the following should the nurse recommend?

Accepted Answer

Answer reason: Constipation in pregnancy is best managed with lifestyle measures such as increased dietary fiber (and fluids/exercise). Routine use of enemas or laxatives is not recommended; decreasing fluids would worsen constipation.

Question 19

Which solution is used for bladder irrigation if there is a contraindication to normal saline?

Accepted Answer

Answer reason: Acetic acid (commonly 0.25%) can be used for bladder irrigation when normal saline is contraindicated; it helps acidify urine and reduce catheter encrustation. Silver nitrate is not used for routine irrigation, and 5% dextrose is not recommended for bladder irrigation.

Question 20

Two hours after the normal spontaneous vaginal delivery of a woman who is gravida 4 para 4, the nurse notes that the fundus is boggy and displaced slightly above and to the left of the umbilicus. The appropriate INITIAL nursing action is to?

Accepted Answer

Answer reason: A boggy uterus displaced above and to one side postpartum suggests bladder distention. The priority initial action is to have the woman void to allow uterine contraction and correct fundal position.

Question 21

The nurse asks the client with an epidural anesthesia to void every hour during labor. The rationale for this intervention is?

Accepted Answer

Answer reason: Epidural anesthesia blocks sensory nerves, reducing or eliminating bladder fullness sensation and causing urinary retention; scheduled voiding prevents overdistention.

Question 22

Constipation is a common problem for immobilized patients because of?

Accepted Answer

Answer reason: Immobility slows GI motility, reducing peristalsis, and bedrest positions make defecation uncomfortable and less effective, promoting constipation. The other options would increase stool passage or are unrelated.

Question 23

To avoid pulling the urinary catheter, where should the nurse tape the catheter on the patient's leg?

Accepted Answer

Answer reason: Securing the Foley to the upper/inner thigh with slack minimizes traction on the urethra during movement, reducing risk of accidental pulling or urethral trauma.

Question 24

The nurse is caring for a newborn who is on strict intake and output. The used diaper weighs 73.5gm. The diaper's dry weight was 62gm. The newborn's urine output is?

Accepted Answer

Answer reason: Weighing diapers: urine volume (mL) equals weight gain (g). 73.5 g − 62 g = 11.5 g ≈ 11.5 mL.

Question 25

The nurse is developing a plan for bowel and bladder retraining for a client with paraplegia. The primary goal of a bowel and bladder retraining program is?

Accepted Answer

Answer reason: Retraining focuses on establishing a regular, continent elimination routine to the greatest extent possible in a client with neurogenic bowel/bladder. Restoring neurosensory function is unrealistic, and prevention of complications is important but not the central retraining goal.

Question 26

The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to?

Accepted Answer

Answer reason: An orthotopic neobladder allows voiding via the urethra; clients often need to use Valsalva/bearing down to empty. The other options refer to stoma care and external pouches, which apply to conduits, not orthotopic replacements.

Question 27

The rationale for inserting a French catheter every hour for the client with epidural anesthesia is?

Accepted Answer

Answer reason: Epidural anesthesia blocks sensory input to the bladder and can impair detrusor function, so the client may not sense bladder fullness and is at risk for urinary retention. Intermittent catheterization is done to empty the bladder.

Question 28

The client with enuresis is being taught regarding bladder retraining. The nurse should advise the client to refrain from drinking after?

Accepted Answer

Answer reason: For nocturnal enuresis, fluid intake is restricted in the evening to reduce nighttime urine production; advise no fluids after about 1900 (7 PM).

Question 29

A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy?

Accepted Answer

Answer reason: In a double-barrel (usually transverse) colostomy, the proximal stoma is the functioning end that expels feces and is located toward the ascending colon, on the client’s right side. The distal stoma (mucous fistula) lies on the left.

Question 30

Which of the following is a Foley catheter?

Accepted Answer

Answer reason: A Foley catheter is an indwelling urinary catheter; the other options are gastrointestinal tubes (Sengstaken-Blakemore, nasogastric, and feeding tubes).

Question 31

The physician orders the removal of an in-dwelling catheter the second post-operative day for a client with a prostatectomy. The client complains of pain and dribbling of urine the first time he voids. The nurse should tell the client that?

Accepted Answer

Answer reason: After catheter removal following prostatectomy, transient dysuria and urinary dribbling are common and typically improve within a few days. Warm compresses are not standard care, Kegel exercises may help later but the immediate response is reassurance, and reinsertion of the catheter is not indicated for expected symptoms.

Question 32

What is the correct position used for flatus tube insertion?

Accepted Answer

Answer reason: A flatus (rectal) tube is inserted with the client in the left lateral/Sims' position, which follows the course of the sigmoid and descending colon and provides safe, easy access while reducing risk of injury.

Question 33

What is the appropriate length to insert a rectal catheter when administering an enema?

Accepted Answer

Answer reason: For an adult enema, insert the rectal tube 7.5–10 cm (3–4 inches). Among the options, 10 cm is correct.

Question 34

What is the term for the expulsion of wastes from the body by the lungs, skin, rectum, and bladder?

Accepted Answer

Answer reason: Elimination is the broad term for removal of body wastes through lungs, skin, rectum, and bladder. Enuresis is involuntary urination, micturition is urination, and defaecation is bowel evacuation.

Question 35

The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?

Accepted Answer

Answer reason: Bowel and bladder retraining is influenced by diet, mobility, and fluid intake; sexual function is unrelated to establishing an elimination program.

Question 36

The nurse is caring for a patient with a colostomy. The patient asks, 'Will I ever be able to swim again?' The nurse's best response would be?

Accepted Answer

Answer reason: Clients with colostomies can bathe and swim; modern ostomy appliances are water-resistant and secure. Options B and C are incorrect restrictions, and D is non-therapeutic.

Question 37

The client with an ileostomy is being discharged. Which teaching should be included in the plan of care?

Accepted Answer

Answer reason: Ileostomy effluent is liquid and enzyme-rich, which can rapidly irritate skin; stomahesive provides the best protective barrier. Ileostomies are not irrigated, Neosporin is unnecessary, and Karaya is less effective with liquid output.

Question 38

To prevent a valsalva maneuver in a client recovering from an acute myocardial infarction, the nurse would?

Accepted Answer

Answer reason: Valsalva results from straining during defecation, which increases intrathoracic pressure and can precipitate dysrhythmias after MI. Routine stool softeners reduce straining. The other options do not prevent straining or are treatment, not prevention.

Question 39

The nurse is caring for a client with a sigmoid colostomy who requests assistance in removing the flatus from a one piece drainable ostomy pouch. Which of the following is the correct intervention?

Accepted Answer

Answer reason: For a one-piece drainable ostomy pouch, gas is properly vented by opening the tail closure at the bottom. Piercing the pouch or breaking the adhesive seal damages the system and risks leakage, and ambulation does not expel gas from the pouch.

Question 40

During urinary catheterization in the male client it is important to lubricate the tip of the catheter prior to insertion to?

Accepted Answer

Answer reason: Lubrication minimizes friction through the male urethra, easing insertion and reducing trauma; it does not directly prevent distention, infection, or leakage.

Question 41

An 82 year-old client complains of chronic constipation. To improve bowel function, the nurse should FIRST suggest?

Accepted Answer

Answer reason: First-line management of constipation in older adults is to increase dietary fiber (about 20–30 g/day) to promote stool bulk and motility. Daily laxatives risk dependence and are not initial therapy; avoiding binding foods and activity balance may help but are secondary.

Question 42

Which position should be provided to a patient when giving an enema?

Accepted Answer

Answer reason: Enemas are administered with the patient in left side-lying (Sims) position to follow the natural curve of the rectum and sigmoid colon and facilitate solution flow. Supine, knee-chest, and lithotomy are not standard for enemas.

Question 43

Which of the following is a use for a Foley catheter?

Accepted Answer

Answer reason: Indwelling Foley catheters are primarily used to relieve or manage urinary retention and allow continuous drainage. They are not standard treatment for enuresis or routine incontinence and would not help anuria (no urine production).

Question 44

A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could BEST handle the problem of voiding on the floor by?

Accepted Answer

Answer reason: Punitive measures or fluid restriction are inappropriate. The safest, most effective intervention is to meet the physical need by providing scheduled, supervised toileting to prevent floor voiding.

Question 45

The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown?

Accepted Answer

Answer reason: Ileostomy effluent is liquid and contains digestive enzymes and bile salts that are highly irritating, causing rapid peristomal skin breakdown. Colostomy output is thicker and less caustic, and an ileal conduit diverts urine, not feces.

Question 46

In counseling a six year-old who experiences secondary enuresis, the school nurse must understand that this is a problem that?

Accepted Answer

Answer reason: Secondary enuresis in children is multifactorial and lacks a single established cause; it is not willful misbehavior, not proven to be due to sleep phobia, and no definite genetic link explains all cases.

Question 47

The nurse is caring for a client with a colostomy. During a teaching session, the nurse recommends that the pouch be emptied?

Accepted Answer

Answer reason: Ostomy pouches should be emptied when 1/3 to 1/2 full to prevent leakage and separation from the skin barrier; fixed times or after every elimination are unnecessary.

Question 48

Which type of enema is administered in case of poisoning?

Accepted Answer

Answer reason: In cases of poisoning, a stimulant enema (e.g., strong coffee) has been used to promote rapid bowel evacuation and provide systemic stimulation that can counteract depressant effects of certain toxins. This helps hasten removal of the toxic substance from the lower bowel. Sedative and emollient enemas are intended to soothe or soften stool and do not aid toxin elimination, and anesthetic enemas are for pain relief rather than decontamination.

Question 49

Enema is given through which route?

Accepted Answer

Answer reason: An enema introduces fluid into the rectum and sigmoid colon to promote bowel evacuation or cleansing. The procedure requires insertion of a lubricated tip into the rectal canal, making the route distinctly rectal. Oral, nasal, and intravenous routes are not used for enemas and would not achieve the intended local gastrointestinal effect.

Question 50

The normal temperature of enema solution for adults is?

Accepted Answer

Answer reason: Enema solutions for adults should be warm and near body temperature to minimize cramping and discomfort and to avoid mucosal injury. Cold solutions (around 20°C) increase intestinal spasm, while very hot solutions (≥45–50°C) can burn the rectal mucosa. Therefore, a temperature close to 37°C is considered appropriate for routine adult enemas.

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