Fundamental Skills - Elimination

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Author:
nursedaisy98
ID:
256718
Filename:
Fundamental Skills - Elimination
Updated:
2014-04-20 10:23:44
Tags:
NCLEX RN
Folders:
Fundamental Skills
Description:
Elimination
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  1. The nurse has administered approximately half of an enema solution to a preoperative client when the client complains of pain and cramping. Which nursing action is most appropriate at this time? 
    1. Reassure the client and continue the flow. 
    2. Raise the enema bag so that the solution can be instilled quickly. 
    3. Discontinue the enema and notify the health care provider (HCP). 
    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.
    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.
  2. A female client states to the home health nurse that she has not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? 
    1. High-fiber diet 
    2. Full liquid diet 
    3. Low-fiber diet 
    4. Low-sodium diet
    1. High-fiber diet
  3. The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position should the nurse place the client to administer the enema?

    1. A 
    2. B 
    3. C 
    4. D
    2. B
  4. The nurse has administered approximately half of an enema solution when the client complains of pain and cramping. Which nursing action is the most appropriate? 
    1. Reassure the client and continue the flow. 
    2. Raise the enema bag so that the solution can be instilled quickly. 
    3. Discontinue the enema and notify the health care provider (HCP). 
    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.
    4. Clamp the tubing for 30 seconds and restart the flow at a slower rate.
  5. Before enema administration, which position should the nurse assists the client to assume? 
    1. Right Sims position 
    2. Dorsal recumbent position 
    3. Left lateral position, with the right leg acutely flexed 
    4. Right lateral position, with the left leg acutely flexed
    3. Left lateral position, with the right leg acutely flexed
  6. The client has a prescription for administering an enema. After preparing the equipment and solution, the nurse should assist the client into which position? 
    1. Left-sided lateral Sims position 
    2. Right-sided lateral Sims position 
    3. Left side-lying, with the head of the bed elevated 45 degrees 
    4. Right side-lying, with the head of the bed elevated 45 degrees
    1. Left-sided lateral Sims position
  7. The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What should the nurse do next? 
    1. Immediately twist the catheter, and then slowly inflate the balloon. 
    2. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. 
    3. Insert the catheter until resistance is met, and then inflate the balloon. 
    4. Withdraw the catheter approximately 1 inch, and then inflate the balloon.
    2. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon.
  8. The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse should take which immediate action? 
    1. Withdraw the catheter slightly and reinflate the balloon. 
    2. Remove the catheter, and reinsert a new one that is one size smaller. 
    3. Finish inflating the balloon; the discomfort is normal and temporary. 
    4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.
    4. Aspirate the fluid, advance the catheter farther, and reinflate the balloon.

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