51

23問 • 2年前

問題一覧

Which statement presents accurate information about the characteristics of human urine

Change in the normal color of urine may be caused by medication’s

The nurse is taking care of a client who weighs 50 KG. What is the estimate amount of urine? The client would be expected to excrete in 24 hours?

1,200 ML

what amount of urine collected and the bladder will normally trigger the urge to void

250ML

A client diagnosed with diabetes has to void urine more often than usual. However, the volume of urine is not increased. What term should the nurse use to describe the client's condition in the electronic medical record?

Frequency

The nurse notices a bright red streak in the stool of an adult client. What is the most likely cause of this observation?

Bleeding in the rectum

A client is suspected of having a gastrointestinal problem from a location in the stomach. What stool characteristic supports that suspicion?

Dark, tarry

Which factor most frequently contributes to a client's chronic constipation?

Ignores the impulse to empty the rectum on a regular basis

Which factors contribute to a client's continuous diarrhea? Select all that apply.

Chronic irritation of the colon, Food poisoning, Parasitic infection, Emotional distress

Which characteristics are associated with fecal impaction? Select all that apply.

Severe abdominal discomfort, Feeling of abdominal pressure, Inability to empty bowel completely, Diarrhea

A 25-year-old male client who is prescribed bathroom privileges has acute diarrhea but is feeling weak and requires assistance in going to the bathroom. What role should the nurse play in such a situation?

Provide the client with instructions and easy access to the call signal while in the bathroom.

A client who is on bed rest is unable to void when using the bedpan. What nursing measures should the nurse implement to help the client urinate? Select all that apply.

Pour warm water over the genitalia., Assist the client in setting upright on the bedpan., Let the client hear the sound of running water.

Which statement accurately describes nursing care for a client prescribed an external catheter?

Remove the sheath and expose the penile skin to the air at intervals during the day.

Which is the correct sequence for bladder training with closed urinary drainage? 1. Open the clamp and allow the bladder to drain by gravity into the drainage bag. Repeat the procedure. 2. Explain the procedure and position the client in the supine position. 3. Record the procedure on the client's electronic medical record, including urinary output. Clamp the catheter tubing for 1 to 2 hours. 4. Put on disposable gloves and clamp the catheter tubing for 1 to 2 hours.

2, 4, 1, 3

What information accurately describes a tap water enema? Select all that apply.

It is a type of purgative enema, it softens the stool in the large intestines, It stimulates intestinal peristalsis

Which is the best description of a carminative enema?

Given to stimulate peristalsis so that flatus is expelled from the intestine.

A nurse is required to administer a cleansing enema to a 9-year-old girl. Which statement accurately describes the administration of this enema to the child?

Insert the rectal tube 2 to 3 in toward the umbilicus.

How long should a client be asked to hold in the fluid introduced by a retention enema?

25 to 30 minutes

The nurse is administering a tap water enema to the client. Which symptom of circulatory overload should the nurse carefully monitor the client for during and after the enema is administered?

Elevated blood pressure

The nurse is digitally removing the impacted feces of a client. What client reports or nursing observations should cause the nurse to immediately stop the procedure? Select all that apply.

Pain, Nausea, Rectal bleeding, Feeling faint

The nurse is reviewing an order for a digital removal of impacted feces of a client. For which clients is digital removal of feces contraindicated? Select all that apply.

Cardiac conditions, Reproductive surgery, Genitourinary surgery, Pelvic fractures

A 40-year-old client has an episode of vomiting. On observation of the vomitus, coffee ground-like material was noticed. What is the most likely cause of this finding?

Bleeding in the lower digestive tract

During episodes of vomiting, what assessment change is often observed?

Blood pressure and pulse decrease

A 40-year-old client has an episode of vomiting. On observation of the vomitus, yellowish-green color was noticed. What is the most likely cause of this finding?

Presence of bile pigments and salts