Question 1

A client with a new colostomy asks a nurse how to avoid leakage from the ostomy bag. Which instruction is correct?

Accepted Answer

Answer reason: Preventing ostomy pouch leakage primarily involves reducing weight and pressure on the skin barrier/wafer and maintaining a secure seal. Emptying the pouch when it is about one-third to one-half full minimizes pulling on the adhesive and decreases the chance of the seal lifting with movement. Limiting fluids is not an appropriate strategy and risks dehydration/constipation, and dietary changes can alter stool volume/gas but do not reliably prevent leakage. Taping the pouch to skin is not a standard fix for leakage and can worsen skin irritation and undermine proper pouching technique.

Question 2

A severely depressed client rarely leaves his chair. To prevent physiological complications associated with psychomotor retardation, which client goal is appropriate?

Accepted Answer

Answer reason: Psychomotor retardation can lead to prolonged immobility and reduced self-care, increasing risk for urinary retention, constipation, dehydration, and related complications. A timed toileting goal supports regular bladder emptying when motivation and initiation are impaired, helping prevent retention, overflow incontinence, and urinary tract infection. This goal is concrete, measurable, and directly targets a common physiologic risk of inactivity and decreased drive. Limiting television time does not address physiologic complications, and resting in bed worsens immobility-related risks; increasing calcium intake is not a primary preventive strategy for this problem.

Question 3

When teaching a client how to prevent recurrences of acute glomerulonephritis, which instruction should the nurse include?

Accepted Answer

Answer reason: Acute glomerulonephritis commonly follows infections—especially streptococcal pharyngitis or skin infections—via an immune-mediated inflammatory response in the glomeruli. Preventing recurrence focuses on prompt recognition and treatment of these precursor infections to reduce antigen exposure and subsequent immune complex activity. Avoiding physical activity is not a prevention strategy; activity restriction is used selectively during acute illness with significant edema or hypertension. Straining urine is more relevant to suspected calculi, and daily urine specific gravity monitoring is not a practical or primary prevention measure for recurrent glomerulonephritis.

Question 4

Which of the following should be part of the teaching plan for a client with hemorrhoids?

Accepted Answer

Answer reason: Increasing dietary fiber (often with adequate fluids) reduces the need to bear down, decreasing venous pressure and irritation of anorectal tissue. This targets the underlying contributing factor rather than providing only short-term symptom relief. Cold applications or topical astringents may offer temporary comfort but do not address the primary prevention goal of minimizing straining; elevating the buttocks is not a standard evidence-based measure for hemorrhoid management.

Question 5

After emptying urine from the bedpan of a client whose urinary output is being monitored, which step should a nurse do next?

Accepted Answer

Answer reason: Accurate intake and output monitoring requires timely measurement and documentation to trend renal perfusion and fluid balance and to detect deterioration early. Recording the volume plus key characteristics (e.g., color, clarity, odor, presence of blood) supports clinical decision-making and establishes a legal record of care. Hand hygiene is essential but is not the next priority step for an output-monitoring task once measurement is complete, because the primary purpose of the activity is tracking and recording output. Immediate reporting is reserved for abnormal findings (e.g., oliguria, gross hematuria) rather than routine measured output.

Question 6

After radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. He then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first?

Accepted Answer

Answer reason: The first-line nursing intervention is pelvic floor muscle training to improve urethral support and urinary control in a safe, noninvasive manner. Restricting fluids can worsen dehydration and bladder irritation without treating the underlying pelvic floor dysfunction. Artificial sphincters and self-catheterization are more invasive measures reserved for persistent, refractory issues or urinary retention rather than initial management of postoperative stress incontinence.

Question 7

The nurse is providing teaching to the client with a noncontinent urostomy created during urinary diversion. Which information should the nurse include?

Accepted Answer

Answer reason: A healthy urostomy should appear moist, beefy red/pink, and slightly raised or protruding from the abdominal surface due to its mucosal tissue and adequate perfusion. Teaching this normal appearance helps the client distinguish expected findings from complications like ischemia (dusky, pale, or black) or infection. Tight-fitting clothing can impair pouch seal or irritate the stoma/peristomal skin rather than being recommended. Intermittent catheterization and pressing on the stoma are inappropriate and can traumatize tissue and increase risk of bleeding and infection.

Question 8

When teaching an elderly client how to prevent constipation, which instruction should the nurse include?

Accepted Answer

Answer reason: Constipation prevention teaching emphasizes promoting normal bowel motility through lifestyle measures. Regular physical activity stimulates peristalsis and supports a consistent bowel pattern, making it broadly appropriate and safe for most older adults when tailored to ability. The fluid option is vague and may be inadequate for many clients, and hydration targets should also consider comorbidities (e.g., heart failure, renal disease). Avoiding grains and nuts reduces dietary fiber and would worsen constipation risk, while adding a specific gram amount of bran is less universally applicable and may cause bloating if not paired with adequate fluids.

Question 9

Which client is at greatest risk for dehydration?

Accepted Answer

Answer reason: A vesicovaginal fistula can cause continuous urine drainage, making it easy for net losses to exceed intake if the client cannot compensate by drinking more. This problem also predisposes to skin breakdown and infection, which can further worsen fluid status through poor intake and systemic stress. In contrast, intracavitary radiation, postoperative vulvectomy status, and tamoxifen therapy are not inherently associated with continuous high-volume fluid loss in the same direct way.

Question 10

Which nursing intervention should be done for a client with urinary calculus?

Accepted Answer

Answer reason: Management of renal/urinary calculi focuses on promoting stone passage, relieving pain, and obtaining the stone for analysis. Increasing oral fluids helps increase urine flow to facilitate movement of the stone through the urinary tract, while straining urine allows retrieval for composition testing and guides prevention. Analgesia (often NSAIDs/opioids per order) addresses renal colic and improves ability to hydrate and ambulate. Limiting fluids can worsen stasis and does not support passage, and routine indwelling catheterization adds infection/trauma risk unless there is urinary retention or obstruction requiring it.

Question 11

Which comment made by a client being treated for chronic prostatitis indicates to the nurse that further teaching is necessary?

Accepted Answer

Answer reason:  Heat therapy for chronic prostatitis is typically recommended as warm sitz baths to reduce perineal discomfort and promote local circulation. Hot tub soaking can expose the perineal/urethral area to irritants and bacteria, potentially worsening inflammation or increasing risk of urinary tract infection, so it suggests misunderstanding of safe symptom-relief measures. By contrast, reducing caffeine is appropriate because it can irritate the bladder and worsen urinary symptoms. Avoiding prolonged sitting and staying mobile helps decrease perineal pressure and can improve discomfort, aligning with recommended self-care teaching.

Question 12

Kegel exercises are used to gain control of bladder function in women with stress incontinence and in some men after prostate surgery. Which instruction would help the client perform these exercises?

Accepted Answer

Answer reason: Kegel exercises aim to strengthen the pelvic floor by isolating and repeatedly contracting the muscles used to stop urine flow. A simple positioning cue that promotes awareness and isolation of these muscles helps clients perform the contractions correctly and avoid substituting thigh, buttock, or abdominal muscles. Keeping the legs together while sitting or standing can facilitate focusing on the pelvic floor squeeze/hold/relax sequence. A high, fixed repetition target is not a standard starting instruction and can encourage fatigue and poor technique, while hydration advice and emptying the bladder are not core instructions for how to perform the contractions.

Question 13

A 54-year-old client who is postmenopausal reports increasing episodes of urinary leakage. Which lifestyle practice is most important for the nurse to discuss with the client?

Accepted Answer

Answer reason: Stress urinary incontinence is commonly associated with decreased pelvic floor support, which can worsen after menopause due to reduced estrogen and tissue tone. Pelvic floor muscle training is a first-line, noninvasive lifestyle intervention that improves urethral support and reduces leakage episodes over time. Caffeine reduction can help if urgency/frequency is prominent, but it does not address the core pelvic support problem as directly. Fluid restriction is unsafe and can concentrate urine and worsen bladder irritation, increasing symptoms and risk for UTI.

Question 14

The nurse caring for the hospitalized school-aged child writes a nursing problem of Altered urinary elimination in the child's plan of care. Which outcome is best for the nurse to include?

Accepted Answer

Answer reason: A typical school-aged child should void about 6–8 times daily, making this a clear, objective target that can be monitored each shift. The kidney “excretory function” outcome is more of a medical/physiologic goal and is not a specific elimination-behavior outcome the nurse can evaluate without diagnostics. Ambulating independently addresses mobility rather than urinary elimination, and “enuresis every other day” is less optimal because it accepts ongoing abnormal elimination rather than aiming for normal patterns.

Question 15

The nurse is providing instruction about skin care at the stoma site for a client with an ileal conduit. What is the most important information for the nurse to provide?

Accepted Answer

Answer reason: Peristomal skin protection is primarily achieved by ensuring the pouching barrier fits closely enough to prevent continuous urine contact with the skin while avoiding pressure on the stoma. A properly sized opening (small clearance) minimizes leakage and chemical irritation/excoriation from alkaline urine and mucus typical of an ileal conduit. General cleansing with mild soap and water is helpful but will not prevent dermatitis if effluent undermines the seal. Changing at bedtime and briefly exposing the stoma to air are minor technique points and are less critical than correct wafer sizing for preventing skin breakdown.

Question 16

The nurse is caring for multiple clients. Which client would be most appropriate for the nurse to plan to instruct on the use of intermittent self- urinary catheterization?

Accepted Answer

Answer reason: A spinal cord injury with absent urge to void strongly suggests impaired bladder emptying and is a classic situation where clean intermittent catheterization is taught for long-term management. In contrast, pre-cesarean catheter use is typically short-term and performed by staff rather than self-taught for ongoing care. Pregnancy-related dribbling is commonly stress incontinence and is managed first with pelvic floor measures and evaluation for obstruction rather than routine intermittent catheterization.

Question 17

The rehabilitation nurse caring for the young client with a T-12 SCI is developing the nursing care plan. Which priority intervention should the nurse implement?

Accepted Answer

Answer reason: With a T12 spinal cord injury, bowel function is commonly neurogenic, making a consistent, scheduled bowel program a key priority to prevent constipation and fecal impaction. A daily rectal stimulant at a consistent time helps establish predictable evacuation by leveraging reflex activity and routine. Urinary catheter monitoring supports safety but is not the foundational long-term rehab priority because the goal is typically bladder program planning and reducing catheter dependence when appropriate. ROM and vocational referral are beneficial rehabilitation measures, but they are secondary to establishing safe, reliable elimination patterns early to prevent complications.

Question 18

The client is scheduled for a cystectomy with an ileal conduit for urinary diversion. Which explanation should the nurse provide when the client asks about postsurgery urination?

Accepted Answer

Answer reason:  An ileal conduit is a noncontinent urinary diversion in which urine drains continuously from the ureters through a segment of ileum to a stoma on the abdominal wall. Because the bladder is removed, the client will not void via the urethra and will not be able to control urinary output. The appropriate teaching is that urine will collect in an external ostomy appliance attached to the stoma. Options suggesting normal urinary flow, continence exercises, or bladder retraining are inconsistent with removal of the bladder and creation of a noncontinent diversion.

Question 19

The nurse is caring for the client who had continent urinary diversion surgery with creation of a Kock pouch. Which intervention should the nurse include in the care?

Accepted Answer

Answer reason: A continent urinary diversion (Kock pouch) stores urine internally and requires intermittent catheterization through the stoma to empty the reservoir and prevent overdistention and reflux. A regular schedule such as every 4–6 hours supports adequate emptying, reduces infection risk, and maintains continence. Alcohol cleansing can irritate and dry peristomal skin; routine care typically uses mild soap/water and gentle drying. External appliance “snug fit” and sleep positioning are priorities for ileal conduits (incontinent diversions) rather than a continent internal reservoir.

Question 20

The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse’s best action?

Accepted Answer

Answer reason: A 24-hour urine test requires a complete collection of all urine produced during the timed interval to yield valid quantitative results. If any urine is missed or discarded, the total analyte amount will be falsely low and the specimen is no longer reliable for interpretation. Restarting the collection right away preserves the integrity of the timed study and minimizes further delay. Continuing the current collection or “making up for it” with an extra specimen does not correct the missing volume and can lead to inaccurate clinical decisions.

Question 21

The client with intermittent abdominal pain recently had a barium enema. The client calls the nurse to report passage of a soft-formed, pale-colored stool. What is the nurse’s best response?

Accepted Answer

Answer reason:  Barium can temporarily lighten stool color because the contrast agent mixes with feces as it is eliminated from the GI tract. A soft, pale/whitish stool shortly after a barium enema is therefore an expected, benign finding that requires reassurance. The priority nursing response is to address the client’s concern by providing accurate normal findings rather than further assessment that does not match the complaint. While hydration is commonly encouraged after barium to reduce constipation risk, the question asks specifically about pale-colored stool, making reassurance the most direct and correct response.

Question 22

The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse’s best action?

Accepted Answer

Answer reason: Pain during balloon inflation indicates the balloon may be inflating in the urethra rather than the bladder, which risks urethral trauma. The safest immediate action is to deflate the balloon completely and advance the catheter until urine flows freely, confirming intravesical placement before re-inflation. Continuing inflation or manipulating/rotating while inflating can worsen mucosal injury and create a false passage. Switching to a smaller catheter does not address the primary problem of incorrect placement and delays correction of a potentially harmful complication.

Question 23

A client has come to the physician’s office complaining of recent constipation. The nurse takes a health history. Which statement made by the client suggests a likely cause of the constipation?

Accepted Answer

Answer reason: The fast food place near my home has really good food. I eat there most of the time. Constipation is commonly caused by inadequate dietary fiber and sometimes inadequate fluid intake, both of which reduce stool bulk and slow colonic transit. A diet heavy in fast food is typically low in fiber (few fruits, vegetables, and whole grains) and higher in refined carbohydrates and fats, making it a plausible precipitating factor in “recent” constipation. Regular daily walking suggests good activity level, which generally helps bowel motility rather than causing constipation. The question about laxatives reflects knowledge deficit, not an etiologic factor for constipation.

Question 24

When assessing a client who just delivered a neonate, a nurse finds the following: blood pressure, 110/70 mm Hg; pulse, 60 beats/minute; respirations, 16 breaths/minute; lochia, moderate rubra; fundus, above the umbilicus to the right; and negative Homan's sign. What is the most appropriate nursing intervention?

Accepted Answer

Answer reason: A boggy or displaced uterus in the immediate postpartum period is commonly caused by a distended bladder, which pushes the uterus up and to the side (often to the right) and increases risk for uterine atony and bleeding. The safest first nursing action is to assist with bladder emptying and then reassess uterine position and tone to confirm it returns to midline and at/below the umbilicus. Fundal massage is indicated when the uterus is boggy/atonic, not as the first step for a classic bladder-distention displacement finding. The vital signs and lochia described are not alarming for hemorrhage, so addressing likely bladder distention is the most appropriate intervention.

Question 25

The nurse is caring for an 82-year-old male client with Parkinson's disease who is frequently incontinent of urine. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: The key principle is to manage urinary incontinence with the least invasive method that protects skin integrity and reduces infection risk. An external (condom) catheter is appropriate for an older male with frequent urinary incontinence because it can collect urine without entering the urinary tract, lowering CAUTI risk compared with an indwelling catheter. Diapers can worsen moisture-associated skin damage and do not actively drain urine, and routine skin care alone does not adequately control ongoing exposure. Indwelling catheterization should be avoided unless there is urinary retention, need for strict output measurement, or another clear indication due to high infection and complication risk.

Question 26

The client was treated for constipation 1 month earlier. On a return clinic visit, which statement would best assist the nurse to evaluate that the client is no longer constipated?

Accepted Answer

Answer reason:  Resolution of constipation is best evaluated by actual bowel pattern and stool characteristics rather than by planned interventions. This statement describes regular passage of soft, formed stool without straining, which indicates adequate colonic motility and ease of defecation over a sustained period. By contrast, reporting fluid/prune juice intake reflects adherence to a prevention strategy but does not confirm the outcome. Needing an enema or having hemorrhoid discomfort suggests ongoing bowel difficulty and does not demonstrate normalization.

Question 27

An elderly client is complaining if increasing trips to the bathroom to urinate. The client’s estimated coffee intake is 3 cups per day. What is the best explanation the nurse can provide to the client?

Accepted Answer

Answer reason: Coffee is causing the increased urination. Coffee contains caffeine that causes diuresis, or increased urine formation. Simply decreasing the number of cups of coffee you drink each day, and limiting the consumption of caffeinated beverages to the morning hours, should help decrease your trips to the bathroom. Caffeine acts as a mild diuretic and bladder irritant, which can increase urinary frequency, particularly in older adults who may have decreased bladder capacity. This option gives an accurate physiologic mechanism and practical, safe behavioral modifications to reduce nocturia and urgency. Attributing symptoms primarily to infection without dysuria, fever, suprapubic pain, or foul/cloudy urine is premature and can lead to unnecessary alarm. Explaining it as “completely normal and nothing to be concerned about” is unsafe because it dismisses symptoms and fails to offer actionable guidance.

Question 28

The nurse is receiving shift report on a client. The client has a urinary catheter with a closed urinary drainage system. Which sites have the greatest potential for introducing infection in the closed urinary drainage system?

Accepted Answer

Answer reason: Infection risk in a closed urinary drainage system is highest at points where the system can be contaminated by touch, backflow, or breaks in the closed circuit. The meatus/insertion site is exposed to perineal flora, and the drainage bag and its outlet spigot are frequently manipulated during emptying, increasing contamination risk if asepsis is not maintained. Junctions (tube junction and the tube-to-bag connection) are high-risk because any disconnection or leakage can introduce organisms into the system and allow ascending infection. Options that omit commonly manipulated access points (especially the spigot and junctions) underestimate the most frequent routes of contamination during routine care.

Question 29

A client was admitted to the medical unit after having abdominal surgery. The nurse questioned the client during the morning assessment about the passage of flatus. The client stated that flatus had been passed early in the morning. In anticipation of defecation, what is the most important instruction for the nurse to give the client?

Accepted Answer

Answer reason: If you feel the urge to have a bowel movement, please call for assistance before getting up to the toilet. When having a bowel movement, be sure to breathe out to prevent straining. Do not hold your breath. After abdominal surgery, the priority is safe toileting while preventing excessive intra-abdominal pressure that can stress the incision and provoke vagal responses. Calling for assistance reduces fall risk related to postoperative weakness, pain, and orthostatic hypotension. Exhaling during defecation helps avoid breath-holding and straining, which can trigger the Valsalva maneuver and hemodynamic instability. A common error is advising the client to bear down with breath held, which directly increases intra-abdominal pressure and is unsafe postoperatively.

Question 30

The nurse is assisting a client with the use of a fracture bedpan. Which action should the nurse take?

Accepted Answer

Answer reason:  Proper fracture bedpan placement uses the smaller/open end under the sacrum (toward the head) so the wider portion supports the buttocks and aligns with the rectum. This positioning promotes effective elimination and reduces the need for excessive hip flexion or rolling, which is important when mobility is limited by injury or precautions. Prone positioning is inappropriate and unsafe for toileting. Lowering all side rails increases fall risk; only the necessary rail(s) should be lowered while maintaining safety.

Question 31

During administration of a saline solution enema, a client reports severe abdominal discomfort and cramping. Which action should the nurse implement next?

Accepted Answer

Answer reason: Severe cramping during an enema commonly indicates the solution is being instilled too quickly or the bowel is reacting with spasm, so the immediate nursing response is to pause the flow to relieve discomfort. Restarting at a slower rate reduces colonic distention and decreases vagal stimulation risk, improving tolerance and safety. Simply reassuring the client is unsafe because severe pain is not an expected finding that should be ignored. Increasing the infusion rate worsens distention and cramping, and changing to another enema type requires a new order and does not address the urgent symptom management during the current procedure.

Question 32

A nurse is caring for a 28-year-old pregnant woman at 34 weeks gestation who is experiencing increased urinary frequency and urgency. Which of the following interventions would be most effective to promote comfort?

Accepted Answer

Answer reason: Late pregnancy commonly causes urinary frequency/urgency from uterine pressure and reduced bladder capacity, so comfort measures focus on supporting effective bladder emptying without creating dehydration or infection risk. Regular bladder emptying helps reduce urgency episodes and can decrease discomfort from bladder distention, while loose clothing reduces external pressure and irritation. Restricting fluids can concentrate urine and increase bladder irritation and UTI risk, worsening symptoms. Timed voiding regardless of urge is more relevant to certain incontinence plans and is less targeted than encouraging regular emptying as needed; avoiding Kegels is inappropriate because pelvic-floor strengthening can help urinary symptoms.

Question 33

The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client?

Accepted Answer

Answer reason: An enema is best administered in the left lateral (Sims) position because it uses the natural anatomic direction of the sigmoid colon and rectum to promote smooth flow of solution. This position also allows easier insertion of the rectal tube and reduces the risk of mucosal trauma. It supports retention of the enema and enhances distribution along the descending colon for more effective evacuation. In contrast, upright or head-down positions can make administration less effective and may increase discomfort or risk of complications such as leakage and cramping.

Question 34

A nurse is providing care for a patient experiencing incontinence of small amounts of urine when coughing, sneezing, or laughing. The nurse should provide teaching to this patient on which type of incontinence?

Accepted Answer

Answer reason: Coughing, sneezing, and laughing transiently raise bladder pressure, overcoming urethral closure when support is inadequate. Teaching typically focuses on pelvic floor muscle (Kegel) exercises, weight management, and avoiding bladder irritants as appropriate. In contrast, urge incontinence is characterized by a sudden intense urge followed by larger-volume leakage from detrusor overactivity, and functional incontinence is due to mobility/cognitive barriers rather than sphincter mechanics.

Question 35

While administering a large volume cleansing enema, which of the following statements would should the nurse say to the patient?

Accepted Answer

Answer reason: During a large-volume cleansing enema, patient safety centers on monitoring tolerance and preventing complications from excessive bowel distention or rapid instillation. Promptly reporting cramping allows the nurse to slow or temporarily stop the flow, lower the container, and encourage slow deep breathing to reduce discomfort and vagal effects. Stating the procedure will take less than five minutes is inaccurate because slower instillation is often required for comfort. Instructing the patient to sit on the toilet while waiting increases fall risk and can lead to premature expulsion rather than therapeutic retention.

Question 36

Which stoma would you expect a malodorous, enzyme-rich, caustic liquid output that is yellow, green, or brown?

Accepted Answer

Answer reason: Stoma output characteristics depend on where the bowel is diverted, with more proximal diversions producing more liquid, more frequent, and more enzyme-containing effluent. An ileostomy drains small-intestinal contents that still contain digestive enzymes and bile, making the output watery to pasty, often yellow-green to brown, and irritating/caustic to peristomal skin. As colonic segments are included (ascending/transverse/descending colostomies), water is absorbed and bacterial fermentation changes the stool to thicker, more formed output, generally less enzyme-rich and less caustic. Therefore the described liquid, enzyme-rich, skin-irritating effluent best matches an ileostomy.

Question 37

Which renal disorder would require the nurse to strain the patient’s urine?

Accepted Answer

Answer reason: Identifying stone composition (e.g., calcium oxalate, uric acid, struvite, cystine) helps guide targeted prevention and dietary/medication recommendations. This action is specifically relevant when stones are suspected or confirmed because fragments may pass intermittently and can be missed without straining. In contrast, acute kidney injury, glomerulonephritis, and nephrotic syndrome are primarily managed with monitoring output, labs, fluids, and medications rather than collecting solid particles from urine.

Question 38

The primary reason for taping an indwelling catheter laterally to the thigh of a male client is to?

Accepted Answer

Answer reason: The core principle is that securement of an indwelling urinary catheter should minimize urethral traction and pressure to prevent tissue injury and discomfort. In males, anchoring the catheter laterally on the thigh helps maintain a gentle curve and reduces pressure/drag at the penoscrotal junction, lowering risk of urethral erosion and pain. While preventing dislodgement is a benefit of securement, the technique and positioning here are specifically aimed at reducing localized pressure at that angle. If pressure/traction persists, complications such as urethral trauma and meatal/urethral breakdown become more likely.

Question 39

SITUATION: A 3-year-old child is seen in the health care clinic and was diagnosed with encopresis. Upon reviewing the child's assessment findings, which the nurse expects to document?

Accepted Answer

Answer reason: The typical assessment cue is repeated stool staining/soiling of underwear or clothing, often with a history of constipation and withholding behaviors. Watery stools can occur as overflow around impaction, but the hallmark finding the nurse would expect to document is soiling. Nausea/vomiting or loss of appetite are not defining findings and would prompt evaluation for other GI illness or complications rather than being expected routine features.

Question 40

Patient X is diagnosed with constipation. As a knowledgeable nurse, which nursing intervention is appropriate for maintaining normal bowel function?

Accepted Answer

Answer reason: Assessing what and how the patient eats helps identify low-fiber patterns, inadequate meal timing, or constipating foods so the nurse can plan appropriate dietary teaching and referrals. Decreasing fluid intake would typically worsen constipation by drying stool and making it harder to pass, while limiting activity reduces gut motility. Turning, coughing, and deep breathing are respiratory-focused interventions and do not directly support bowel regularity.

Question 41

Nurse Anna is administering a cleansing enema to a client with severe constipation. She will place the client in which position?

Accepted Answer

Answer reason: Enema administration is optimized by positioning that uses gravity and the natural anatomy of the sigmoid colon and rectum to promote fluid flow and retention. Left lateral (Sim’s) positioning aligns the rectosigmoid curve and allows the enema solution to flow more easily into the descending/sigmoid colon while reducing risk of discomfort and mucosal trauma. It also provides good access for safe rectal tube insertion and helps the client tolerate the procedure. Right Sim’s is less ideal because it does not align the sigmoid colon as effectively for solution distribution during a cleansing enema.

Question 42

A nurse is monitoring the intake and output of an infant receiving furosemide (Lasix) IV. Which of the following methods is the most appropriate in measuring the urine output?

Accepted Answer

Answer reason: Diaper-counting is subjective and does not quantify volume, and simply comparing intake with output does not provide a direct measurement. Indwelling Foley catheterization is invasive and increases infection risk, so it is reserved for situations requiring precise measurement when noninvasive methods are not feasible. With IV furosemide, close, quantitative monitoring is needed to detect excessive diuresis and related dehydration/electrolyte imbalance early.

Question 43

Nurse Maria is administering a cleansing enema to a client with severe constipation. She will place the client in which position?

Accepted Answer

Answer reason: Enema administration follows the principle of using anatomy and gravity to allow the solution to flow along the natural curve of the sigmoid colon and into the descending colon. Placing the client on the left side with the right knee flexed helps the rectal tube follow rectal anatomy more easily, improving comfort and reducing risk of mucosal trauma. This position also supports better retention and distribution of the enema solution compared with upright Fowler’s positions, which are not standard for enema insertion. Right Sims’ is less optimal because it does not align as well with the direction of colonic flow for effective instillation.

Question 44

A nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse places the client in which position?

Accepted Answer

Answer reason: This side-lying posture with the right knee flexed facilitates easier, less traumatic rectal tube insertion and promotes flow of solution into the descending/sigmoid colon to help soften and mobilize stool in impaction. A right-side Sims’ position does not align as well with colonic anatomy for typical enema flow. Elevating the head of the bed is unnecessary for a standard cleansing enema and may reduce comfort and retention.

Question 45

The nurse is developing a bowel-retraining plan for a client with multiple sclerosis. Which measure is likely to be least helpful to the client?

Accepted Answer

Answer reason: Restricting fluids commonly hardens stool, worsens constipation, and undermines the effectiveness of a scheduled toileting program, which is a frequent need in multiple sclerosis due to neurogenic bowel and decreased mobility. In contrast, establishing regular toileting times helps leverage the gastrocolic reflex and promotes predictable evacuation. A high-roughage diet supports stool bulk, and adaptive equipment such as a raised toilet seat can improve safe, timely access and reduce delays that contribute to constipation.

Question 46

SITUATION: A 35-year-old is being treated with skeletal traction after suffering from a fractured femur. He states that he has not had a bowel movement for two (2) days. Which of the following interventions would be most appropriate?

Accepted Answer

Answer reason: Immobilization and reduced activity in skeletal traction slow intestinal motility, so first-line nursing care focuses on noninvasive measures that soften stool and promote peristalsis. Encouraging adequate oral fluids increases stool water content and helps prevent constipation caused by inactivity and often concurrent analgesic use. A tap-water enema is more invasive and typically reserved for constipation that does not respond to conservative measures or when rapid relief is needed. Scheduled bedpan use supports toileting habits but does not address hard stool/dehydration as directly as improving hydration status.

Question 47

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?

Accepted Answer

Answer reason: Clean intermittent catheterization at a frequent interval (about every 2–4 hours initially, then individualized) is a standard rehab approach to maintain low bladder pressures and predictable elimination. An indwelling catheter increases infection risk and is generally avoided long-term in rehabilitation when intermittent catheterization is feasible. Catheterizing only every 8 hours is typically too infrequent early on and can allow excessive bladder filling, while Crede’s maneuver can raise intravesical pressure and promote reflux, making it a less safe routine strategy.

Question 48

The nurse is administering cleansing enemas to a client the night before bowel surgery. During instillation of the enema, the client reports cramping and pain. What action should the nurse take?

Accepted Answer

Answer reason: Temporarily stopping the flow allows the bowel to relax and decreases discomfort, and restarting more slowly reduces further distention and pain. This action is the safest immediate nursing intervention while maintaining the goal of bowel cleansing. Deep breathing may provide minimal comfort but does not address the physiologic cause, and repositioning/withdrawing the tube is more appropriate when there is resistance to insertion or suspected mucosal irritation rather than simple cramping from rate.

Question 49

Which focus is the nurse most likely to teach for a client with a flaccid bladder?

Accepted Answer

Answer reason: A flaccid (areflexic) bladder typically results from lower motor neuron dysfunction, leading to poor detrusor contraction and urinary retention with overflow. Management teaching focuses on methods to assist bladder emptying, such as manual expression or intermittent catheterization, rather than suppressing urgency. Gentle suprapubic pressure can help increase intravesical pressure to facilitate voiding when detrusor tone is reduced. Bladder training and Kegel exercises are more useful for spastic bladder/urge incontinence or stress incontinence, not for an areflexic retention problem. The priority is preventing overdistention, retention, and associated infection risk by promoting effective emptying.

Question 50

The nurse cares for a group of clients. Which client is most at risk for constipation?

Accepted Answer

Answer reason: On postoperative day 2 after bilateral hip arthroplasty, the client is likely immobile and receiving opioids, which slow GI motility and increase stool water absorption. NPO status for a CT is typically short-term and less constipating than sustained immobility plus opioids. Antibiotics more commonly cause diarrhea, and corticosteroids are not a primary constipation trigger compared with postop immobility/opioids.

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