Question 1

You’re caring for Carin who has just had ileostomy surgery. During the first 24 hours post-op, how much drainage can you expect from the ileostomy?

Accepted Answer

Answer reason: Immediately after an ileostomy, effluent is watery and high-volume due to unregulated small-bowel secretions. Typical output in the first 24 hours is about 1000–1500 mL before it gradually decreases over the next days to weeks. Recognizing this expected range helps the nurse monitor for dehydration and electrolyte loss. Therefore, 1500 mL is the best estimate for the first postoperative day.

Question 2

The usual amount of fluid used for adult cleansing enema is?

Accepted Answer

Answer reason: For an adult cleansing enema, the standard volume is 500–1000 mL to produce sufficient distention of the colon and stimulate peristalsis for evacuation. Smaller volumes (50–200 mL) are typical for hypertonic or oil-retention enemas rather than cleansing enemas. A 2000 mL volume is excessive and increases risk of cramping, mucosal injury, and fluid/electrolyte imbalance.

Question 3

The enema nozzle should be inserted about?

Accepted Answer

Answer reason: For an adult, the enema tip is inserted 3–4 inches (approximately 7–10 cm) to pass the internal anal sphincter and deliver the solution into the rectum. Inserting less may lead to leakage and ineffective delivery, while deeper insertion increases risk of mucosal injury or perforation. The nozzle should be well lubricated and directed toward the umbilicus with the client in left Sims’ position.

Question 4

The position used for giving enema is?

Accepted Answer

Answer reason: Enemas are administered with the client in the left lateral (Sims) position. This places the sigmoid colon lower than the rectum, allowing the solution to flow by gravity into the descending colon and improving retention. Flexing the right knee also relaxes the rectal sphincter and reduces risk of bowel perforation. Other positions do not optimize colon anatomy for safe, effective enema delivery.

Question 5

The main purpose of a cleansing enema is to?

Accepted Answer

Answer reason: A cleansing enema is primarily used to stimulate peristalsis and evacuate feces to clear the lower bowel, commonly for constipation or to prepare the bowel for procedures. Its intended outcome is bowel emptying/cleansing rather than hemostasis, analgesia, or appetite stimulation. While relieving discomfort from fecal impaction may occur secondarily, the main purpose remains bowel cleansing.

Question 6

The most common solution used for cleansing enema is?

Accepted Answer

Answer reason: A cleansing enema commonly uses an isotonic solution to stimulate evacuation while minimizing fluid and electrolyte shifts across the intestinal mucosa. Normal saline is isotonic, making it safer than plain water or irritating additives for routine cleansing. Soap-suds (soap water) is a type of cleansing enema but is more irritating to the mucosa and is not the preferred “most common” safe solution. Milk and molasses and oil are specialty enemas (hyperosmotic/retention) rather than standard cleansing solutions.

Question 7

The container for enema should be hung about how high above the bed?

Accepted Answer

Answer reason: For a cleansing enema, the container is typically hung about 30–45 cm (12–18 inches) above the rectum/bed to provide adequate gravity flow while minimizing excessive pressure. Hanging it too high (e.g., 1 meter) increases hydrostatic pressure and can cause cramping, rapid infusion, and mucosal irritation. Hanging it too low (e.g., 10 cm) may result in inadequate flow and ineffective instillation. Therefore, 30–45 cm is the safest effective height.

Question 8

Which patient population is most likely to require the use of a urinary catheter?

Accepted Answer

Answer reason: Urinary catheterization is commonly indicated to relieve acute or chronic urinary retention when the patient cannot empty the bladder effectively. Decompression helps prevent bladder overdistention, pain, and potential complications such as hydronephrosis and kidney injury. Healthy young adults typically do not require catheterization, and a broken arm or skin conditions alone are not standard indications. Because catheter use increases CAUTI risk, it should be used only when clinically necessary—such as retention.

Question 9

After giving enema, the patient is instructed to?

Accepted Answer

Answer reason: After an enema, the patient is typically instructed to retain the solution for several minutes to allow it to soften stool and stimulate peristalsis for effective evacuation. Immediate ambulation is not necessary and may increase urgency and leakage before the enema has time to work. Sleeping on the right side is not the standard post-enema instruction (left lateral positioning is commonly used during administration). Drinking water may be helpful for constipation generally but is not the key immediate instruction after administering an enema.

Question 10

Which position is used for rectal suppository insertion?

Accepted Answer

Answer reason: Sims’ (left lateral) position is the standard position for rectal suppository insertion because it provides optimal access to the rectum while maintaining patient comfort and privacy. Flexing the upper leg helps relax the anal sphincter and aligns the rectum to facilitate easier insertion and retention. Fowler’s does not provide good rectal access, prone is less comfortable and less commonly used, and lithotomy is typically reserved for gynecologic/perineal procedures rather than routine suppository administration.

Question 11

Enema can be used for which of the following purposes?

Accepted Answer

Answer reason: Enemas are commonly used to relieve constipation and fecal impaction by softening stool and stimulating bowel evacuation. They can also be used to deliver medications rectally (e.g., retention enemas with anti-inflammatory agents or other prescribed drugs). Additionally, enemas have diagnostic/preparatory uses, such as bowel cleansing before certain imaging or endoscopic procedures. Therefore, all listed purposes are valid.

Question 12

A nurse is preparing to administer an enema to a 10-month-old infant. Which of the following actions should the nurse plan to take?

Accepted Answer

Answer reason: For an infant, holding the buttocks together after instilling the enema helps retain the solution long enough to soften stool and stimulate evacuation, improving effectiveness and reducing immediate leakage. The other options are unsafe or incorrect for infants: tap water can lead to fluid and electrolyte shifts, 7.5 cm insertion is too deep and risks mucosal injury/perforation, and upright positioning is not appropriate for administration. Standard infant technique emphasizes gentle insertion, age-appropriate solution, and measures to retain the fluid briefly.

Question 13

Which clinical condition indicates the need for insertion of a Foley catheter?

Accepted Answer

Answer reason: A Foley (indwelling urinary) catheter is primarily indicated to relieve or manage urinary retention by providing continuous bladder drainage. It may also be used for accurate urine output measurement in critically ill patients, but among the given options, urinary retention is the clearest appropriate indication. Anuria is absence of urine production (catheter won’t treat the cause), and routine use for enuresis or incontinence is inappropriate due to increased risk of CAUTI and urethral trauma.

Question 14

Which is the most suitable position for giving an enema?

Accepted Answer

Answer reason: The left lateral (Sims) position is preferred for enemas because it follows the natural anatomical curve of the sigmoid colon and allows gravity-assisted flow of solution into the descending/sigmoid colon. This position also improves patient comfort and helps retention of the enema. Right lateral, prone, and lithotomy positions are generally less effective or less comfortable for routine enema administration.

Question 15

A child with enuresis is undergoing bladder retraining. Nurse Baker is providing education to the parents. What time should the nurse advise limiting the child's fluid intake?

Accepted Answer

Answer reason: For nocturnal enuresis/bladder retraining, the goal is to reduce nighttime urine production while maintaining adequate daytime hydration. Limiting fluids in the evening (typically a few hours before bedtime) helps decrease bladder filling overnight and reduces episodes of bed-wetting. Restricting fluids earlier in the day (morning or midday) risks dehydration and does not specifically target nighttime enuresis. Therefore, advising to limit intake around 7 PM is the best option among the choices.

Question 16

A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which of the following interventions is important?

Accepted Answer

Answer reason: With suspected or confirmed urolithiasis, straining all urine is important to capture any passed stone for analysis, which guides prevention and future management. Limiting fluids is generally incorrect; adequate hydration is typically encouraged unless contraindicated to promote urine flow and help passage. Strict bed rest is not required and may worsen comfort and mobility without benefit. A high-calcium diet is not routinely recommended as an acute intervention and can be inappropriate depending on stone type.

Question 17

What is the correct position for a patient receiving a rectal suppository?

Accepted Answer

Answer reason: The left lateral (Sims) position is preferred for rectal suppository administration because it follows the natural anatomical curve of the rectum and sigmoid colon, facilitating easier insertion and retention. Flexing the right hip and knee helps relax the external anal sphincter and improves access. Prone and supine positions make insertion more difficult and less comfortable, and right lateral is less optimal anatomically than left lateral.

Question 18

The nurse is creating a presentation for nursing students about enema administration. Which of the following teaching points should the nurse include?

Accepted Answer

Answer reason: Safe enema administration includes lubricating the rectal tip and inserting it about 3–4 inches in an adult, directing the tip toward the umbilicus to follow the natural curvature of the rectum and reduce risk of mucosal trauma or perforation. Infusing as fast as possible is incorrect because rapid instillation increases cramping and discomfort. Keeping the bag as high as possible is incorrect because excessive height increases flow rate and discomfort; a moderate height is used. Supine with legs bent is not the preferred position; the left lateral (Sims) position promotes flow along the descending colon.

Question 19

Appropriate size of rectal tube for giving enema for infant is-?

Accepted Answer

Answer reason: Infants require a small-diameter rectal tube to minimize the risk of mucosal trauma, rectal perforation, and vagal stimulation during enema administration. Standard nursing guidance recommends using approximately size 8–10 for infants, with larger sizes reserved for older children and adults. Options like 12, 16, and especially 22–24 are too large for an infant and increase the risk of injury and discomfort.

Question 20

Which of the following best describes a healthy stoma?

Accepted Answer

Answer reason: A healthy stoma should appear moist and beefy red/pink, reflecting adequate perfusion and viable mucosa. Slight protrusion above the abdominal surface is expected with many ostomies and helps prevent leakage/skin breakdown. Findings such as pallor, dryness, greying/whitening, blue-tinging, bruising, or retraction below skin level suggest ischemia, necrosis, trauma, or other complications requiring prompt evaluation.

Question 21

Size of rectal tube used in adult while giving enema is?

Accepted Answer

Answer reason: This is the commonly recommended French size range for an adult rectal tube/enema tip to allow adequate flow while minimizing mucosal trauma. Smaller sizes are more typical for pediatric clients and may impede flow in adults. Very large sizes can increase discomfort and risk of rectal injury, especially if inserted improperly or in clients with fragile mucosa. Appropriate sizing supports safe, effective bowel elimination procedures.

Question 22

A cleansing enema has been prescribed by the health care provider for an adult client. Directions were provided by the nurse to an unlicensed assistive personnel (UAP) who is trained and certified to administer enemas and should tell the UAP that the maximum volume of fluid that can be administered is which volume?

Accepted Answer

Answer reason: Adult cleansing enemas typically use large-volume solutions, commonly ranging from about 750 to 1000 mL depending on patient tolerance and clinical context. The maximum standard volume referenced for an adult cleansing enema is 1000 mL to promote effective colonic distention and evacuation. Smaller volumes (e.g., 100–500 mL) are more consistent with retention enemas or pediatric/special circumstances rather than a full adult cleansing enema. Using an appropriate maximum helps balance effectiveness while limiting discomfort and risk of adverse effects.

Question 23

A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

Accepted Answer

Answer reason: A bowel-training program after spinal cord injury relies on establishing a consistent routine and using pharmacologic/rectal stimulation to trigger a predictable bowel movement. Giving a suppository shortly before the planned time supports reflex emptying and helps prevent constipation and unplanned stooling. The other options are not appropriate for bowel training: limiting fluids promotes constipation, refined grains reduce fiber, and a cold drink is not the typical gastrocolic-stimulus strategy used in structured programs.

Question 24

A client with a new colostomy asks about pouch care. Which instruction is correct?

Accepted Answer

Answer reason: Emptying the pouch at this level helps prevent excess weight from pulling on the wafer and loosening the seal, which reduces leakage and skin breakdown. It also decreases pouch bulging and odor, supporting comfort and hygiene. Other options are unsafe: monthly changes are too infrequent, alcohol can irritate and damage stoma/peristomal tissue, and overly tight adhesives increase risk of skin injury.

Question 25

The nurse is assessing a patient for constipation. Which of the following is the first the nurse should conduct in order to identify the cause of the constipation?

Accepted Answer

Answer reason: Establishing the patient’s baseline bowel habits is the priority assessment because “constipation” is defined relative to the individual’s normal frequency, stool characteristics, and ease of passage. This first step helps differentiate true constipation from a normal variation and guides targeted follow-up questions about recent changes. Only after clarifying baseline patterns should the nurse focus on contributing factors such as mobility, medications, diet/fluids, and substance use.

Question 26

Which position is used for giving enemas?

Accepted Answer

Answer reason: This position (left Sims) follows the natural anatomic curve of the sigmoid colon, allowing the enema solution to flow more easily into the lower bowel. It also promotes patient comfort and helps reduce the risk of bowel injury during rectal tube insertion. Other positions listed are not the standard, safest positioning for routine enema administration.

Question 27

Position for enema administration?

Accepted Answer

Answer reason: This position uses gravity and the natural anatomy of the sigmoid colon to facilitate smooth flow of solution into the rectum and lower colon. It also allows better relaxation of the abdominal muscles and improves patient comfort and privacy during the procedure. Supine and high Fowler’s positions are not optimal for the flow path, and right lateral positioning is generally less effective than left lateral for following colonic curvature.

Question 28

Best position for a patient undergoing rectal examination or suppository administration?

Accepted Answer

Answer reason: ' This position provides optimal access to the rectum while promoting patient comfort, privacy, and relaxation of the external anal sphincter. The left side-lying posture also follows the natural anatomic direction of the sigmoid colon, helping facilitate insertion of a suppository and reducing risk of trauma. Supine and Trendelenburg do not provide appropriate exposure or comfort for the procedure, and right lateral is less commonly preferred for alignment with colonic anatomy.

Question 29

Position used for giving enema ?

Accepted Answer

Answer reason: This positioning also reduces discomfort and helps the fluid travel up the descending colon with gravity and peristalsis. Right lateral positioning is less effective because it does not align as well with the sigmoid/descending colon pathway. Dorsal recumbent and lithotomy are used for other procedures and generally do not facilitate optimal enema flow and retention.

Question 30

The nurse is developing a care plan for a patient who is taking an anticholinergic drug. Which nursing diagnosis would be appropriate for this patient?

Accepted Answer

Answer reason: In the genitourinary tract this reduces detrusor contraction and can increase sphincter tone, leading to impaired bladder emptying and retention. This effect is a common, predictable adverse effect and therefore a high-priority nursing diagnosis to anticipate and monitor (I&O, bladder distention, hesitancy). Diarrhea is less consistent with anticholinergic effects, which more typically slow GI motility and contribute to constipation rather than increased stooling.

Question 31

The nurse is caring for a 32-yr old client who has multiple sclerosis who has urinary retention. Which intervention would be inappropriate for this client?

Accepted Answer

Answer reason: Markedly restricting fluids can concentrate urine, increase urinary stasis/irritation, and raise the risk of UTI and stone formation, making this an unsafe and inappropriate intervention. Cholinergic agents may be used to stimulate detrusor contraction in certain retention patterns, and teaching techniques to aid bladder emptying (e.g., Credé maneuver when ordered/appropriate) supports elimination. Monitoring for early infection signs is essential because retention predisposes to UTIs and can worsen neurologic symptoms.

Question 32

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: A pouch that is more than half full is more likely to pull away from the wafer during movement, increasing odor and infection/irritation risk. Teaching an objective threshold (about one-third to one-half full) promotes consistent self-management regardless of output timing. The other timings are less reliable because colostomy output can vary with diet, activity, and individual bowel patterns.

Question 33

What nursing assessment of a paralyzed client would indicate the probable presence of a fecal impaction?

Accepted Answer

Answer reason: In a paralyzed client with decreased sensation and reduced bowel motility, this seepage is a classic assessment clue that the rectum may be packed with stool even though diarrhea-like output is seen. By contrast, simple absence of bowel movements is nonspecific and may reflect constipation without impaction. Blood in stool suggests mucosal injury or other GI pathology and is not the hallmark sign used to suspect impaction at the bedside.

Question 34

The nurse is teaching an 87 year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID?

Accepted Answer

Answer reason: Regular laxative use can worsen constipation over time by reducing colonic tone and creating a cycle of increasing use. For maintaining regular bowel movements, safer first-line approaches include adequate fiber, fluids, activity, and if needed a gentle stool softener, rather than chronic laxative use. Rectal agents like glycerin may be used intermittently for short-term relief but do not carry the same dependence risk as habitual laxative use.

Question 35

Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?

Accepted Answer

Answer reason: In older adults, constipation is frequently related to low fiber intake, inadequate fluids, reduced mobility, medication effects (e.g., opioids, anticholinergics, iron), and toileting habits, all best uncovered through a focused health and diet history. This information guides safe first-line nursing interventions such as increasing fluids/fiber, activity as tolerated, and reviewing bowel regimen needs. A CBC does not directly evaluate constipation, and referral for a physical exam is appropriate later if red flags exist (e.g., obstruction symptoms, GI bleeding, weight loss, persistent/new change).

Question 36

A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

Accepted Answer

Answer reason: Tylenol 3 contains codeine, so several days without a bowel movement strongly suggests opioid-induced constipation and warrants bowel regimen and assessment for ileus/obstruction. Bruising and decreased platelet count are more consistent with bleeding or hematologic effects, not typical for acetaminophen/codeine. An elevated heart rate is nonspecific and more commonly reflects pain, hypovolemia, fever, or anxiety rather than a direct expected effect of this medication.

Question 37

A 60 year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

Accepted Answer

Answer reason: Upright positioning uses gravity and helps relax pelvic floor muscles, which can improve detrusor contraction and reduce functional outlet resistance. Offering large amounts of water is unlikely to promptly relieve retention and may worsen bladder overdistention while waiting for diuresis. Credé maneuver is not first-line because it can cause trauma, increase intravesical pressure, and is inappropriate if obstruction is present; if noninvasive strategies fail, bladder scanning and catheterization are typically needed to prevent overdistention.

Question 38

The nurse is inserting a Foley catheter into the bladder of a female adult client. The nurse slips the catheter into an opening for four-5 inches and no urine is obtained. The most probable reason for this is that?

Accepted Answer

Answer reason: The vagina can accept the catheter to that depth without urine return because it is not connected to the urinary tract. If the catheter were simply not far enough, advancing slightly should produce urine rather than no return after several inches. Absence of urine in the bladder is possible but less likely than incorrect placement when the insertion depth is already excessive for the female urethra.

Question 39

A client being treated for hypertension returns to the community clinic for follow up. The client says, "I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom." Which of these is the best nursing diagnosis?

Accepted Answer

Answer reason: The client clearly links stopping the diuretic to bothersome urinary frequency that interferes with job demands, which is a medication effect driving medication-taking behavior. This fits a nonadherence/noncompliance-type diagnosis with the related factor being side effects. A knowledge deficit is less supported because the client acknowledges the pills are important, suggesting understanding rather than misunderstanding.

Question 40

A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?

Accepted Answer

Answer reason: Rectal medication administration is positioned to promote comfort and optimal retention, with the left lateral (Sims) position preferred because it follows the natural direction of the sigmoid colon and reduces expulsion. Turning the client to the right side shortly after insertion can increase the likelihood the suppository will slip out or be less effectively retained. The insertion depth described (to about the second knuckle) is generally adequate for an adult, so the key correction is maintaining or returning to the left-side position rather than questioning technique without addressing the positioning issue. Asking about stool or “checking if it’s far enough” is less appropriate and may be unnecessary or invasive when the primary observed problem is the post-insertion position change.

Question 41

The nurse is preparing to administer medications to a client with pneumonia who had five liquid bowel movements so far today. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: Withholding the laxative is an immediate, safe nursing action that prevents worsening diarrhea while further assessment (medication review, stool characteristics, hydration status) is performed. Antidiarrheals like loperamide are not first-line without evaluating for infectious causes (e.g., C. difficile) and may be contraindicated if suspected. Scheduled antibiotics for pneumonia generally should not be held without a specific provider order because delaying therapy can worsen the infection; diet changes are supportive but do not address the iatrogenic cause as directly as holding the laxative.

Question 42

Solution used for bladder irrigation is ...?

Accepted Answer

Answer reason: Normal saline is isotonic and is the standard irrigant for catheter patency, clot evacuation (e.g., post-TURP), and continuous bladder irrigation. Sterile water is hypotonic and can contribute to hemolysis and hyponatremia if absorbed, particularly with large-volume irrigation. RL is not routinely used for bladder irrigation compared with normal saline, and glycerol is not an appropriate irrigating solution for this purpose.

Question 43

The nurse is changing the diaper of a 7-month-old client suspected of having Celiac disease. The nurse observes a large, pale, oily stool that is malodorous. The nurse should document this stool as?

Accepted Answer

Answer reason: Large, pale, oily, foul-smelling stools reflect fat malabsorption, a classic elimination finding in celiac disease due to small-intestinal villous damage. This presentation is most precisely documented as fatty stool rather than the nonspecific term diarrhea. Hematochezia refers to bright red blood per rectum and melena refers to black, tarry stools from upper GI bleeding, neither of which matches the observed characteristics. Accurate stool terminology supports appropriate diagnostic evaluation for malabsorption and nutritional deficiencies.

Question 44

During an interview, the nurse discovers that the spouse of a debilitated, chronically constipated client digitally removes stool from the client's rectum. What response to disimpaction is the nurse attempting to prevent by presenting other strategies to regulate the client's bowel movements?

Accepted Answer

Answer reason: Increased vagal tone decreases SA and AV node firing, leading to bradycardia and potentially hypotension or syncope, especially in debilitated clients. Preventing recurrent impaction with a bowel regimen reduces the need for disimpaction and therefore reduces this reflex risk. A common distractor is tachycardia, but the clinically concerning reflex with rectal manipulation is vagally mediated slowing of the heart, not sympathetic acceleration.

Question 45

A client reports a lot of gas in his colostomy bag. What is the best intervention by the nurse?

Accepted Answer

Answer reason: Ostomy pouches can accumulate gas, causing ballooning, discomfort, and risk of seal leakage; the immediate nursing intervention is to safely vent the gas. Venting (“burping”) a drainable pouch relieves pressure without breaking asepsis or compromising the pouch system. Replacing the bag is unnecessary unless there is leakage, skin breakdown, or appliance failure. Creating a hole would damage the pouch and increase odor and infection/leak risk, while dietary teaching is helpful longer-term but does not address the immediate problem.

Question 46

An 80-year-old male client reports urine retention. Which factor may contribute to this client's problem?

Accepted Answer

Answer reason: Age-related prostatic enlargement can compress the urethra and impede urine flow, leading to hesitancy, weak stream, incomplete emptying, and retention. This mechanism directly explains the symptom pattern in an 80-year-old male. Diabetes can contribute via autonomic neuropathy causing impaired detrusor contraction, but this is less classically the primary cause compared with obstructive prostate enlargement in this demographic.

Question 47

A child in a hip-spica cast needs to be toileted. How should the nurse position the child?

Accepted Answer

Answer reason: Positioning the child with the hips/buttocks dependent promotes drainage into the bedpan or diaper area rather than backflow into the cast edges. This also helps keep the perineal area accessible for cleansing and reduces moisture retention under the cast. Positions that place the trunk lower increase the risk of waste tracking toward the cast and make hygiene more difficult.

Question 48

A client is diagnosed with cystitis. The nurse provides teaching aimed at preventing a recurrence. Which instruction does the nurse provide to the client?

Accepted Answer

Answer reason: Cystitis recurrence prevention focuses on reducing periurethral moisture and irritation that promote bacterial growth and ascending infection. Breathable cotton underwear decreases heat and moisture retention compared with non-cotton fabrics, helping limit local bacterial proliferation. Feminine hygiene sprays can irritate mucosa and alter normal flora, increasing infection risk. Tub baths can facilitate urethral contamination in some clients, and cranberry products are sometimes encouraged rather than restricted in prevention teaching.

Question 49

Which nursing intervention would be the most appropriate for a client with postoperative urinary retention?

Accepted Answer

Answer reason: Initial management of postoperative urinary retention prioritizes noninvasive measures that promote relaxation of the urinary sphincter and stimulate the voiding reflex while minimizing infection risk. Warm water over the perineum can trigger detrusor contraction and facilitate urination, making it an appropriate first-line nursing intervention. Catheterization can relieve retention but is more invasive and increases the risk of urinary tract infection, so it is typically considered after conservative measures fail or if bladder distention is significant. A diuretic may worsen bladder overdistention by increasing urine production without resolving outlet dysfunction. Laying the client flat does not aid voiding and may make urination more difficult than positioning the client upright.

Question 50

A client with a spinal cord injury has a neurogenic bladder. When planning for discharge, the nurse anticipates the client will need which procedure or program?

Accepted Answer

Answer reason: Clean intermittent catheterization is the standard first-line management because it supports complete, scheduled emptying while preserving renal function and minimizing complications compared with chronic indwelling drainage. The other options are major surgical urinary diversions or procedures aimed at different pathology and are not typical discharge planning for uncomplicated neurogenic bladder. Nursing discharge teaching also aligns with this option because it focuses on a home program the client can perform safely.

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