Bowel and Urinary Elimination
What are ways to prevent UTI
Promote adequate hydration:
Encourage proper perineal hygiene
Promote regular voiding
When placing catheters use aseptic technique
A nurse is teaching a client who has left hemiparesis how to use a cane. Which of the following instructions should the nurse include?
Hold the cane on the right side to provide support for the weaker leg.
A nurse is preparing a client for continuous cardiac monitoring using a 5-lead telemetry system. Which of the following electrode placements is correct?
RA on right upper chest, LA on left upper chest, RL on right lower abdomen, LL on left lower abdomen, V at the 4th intercostal space right sternal border
A nurse is caring for a client receiving total parenteral nutrition (TPN). The TPN solution runs out, and a new bag is not immediately available. Which action should the nurse take?
Get order to hang D10
A patient with a DNR order goes into cardiac arrest. Family members demand resuscitation. What is the best action?
Explain and honor the DNR order
Four hours after surgery, a patient reports abdominal discomfort and has a distended abdomen with absent bowel sounds. The nurse recognizes these findings as expected early postoperative effects. What is the most appropriate nursing action?
Encourage turning and ambulation to stimulate peristalsis
A nurse is caring for a client whose right leg is in Buck's traction. Which of the following interventions should the nurse implement to promote the client's mobility?
Active range-of-motion exercises of the left leg
A patient on continuous telemetry has a suddenly irregular heart rhythm. The nurse assesses the patient and notes dizziness, decreased blood pressure, and cool extremities. Which cues indicate decreased cardiac output? Select all that apply.
Decreased blood pressure during assessment
Cool extremities with delayed capillary refill
A nurse just placed an Nasogastric tube. What should they do to confirm placement?
Have an xray completed
Which behaviors indicate anticipatory grief?
Withdrawal from social interaction
Expressing sadness about future loss
Increased anxiety about death
A nurse is teaching a patient with a new ileostomy how to protect the surrounding skin. The patient asks what to do when the pouch begins leaking. Which action should the nurse instruct the patient to take?
Replace the entire pouching system immediately to prevent skin irritation
A nurse is caring for a client who has been on bed rest for several days. Which findings indicates a complication of immobility?
Calf/ Leg swelling - DVT
Lung issues such as Pneumonia
Skin breakdown- ulcers
Constipation
Clinical Manifestations of Irregular Heart Rhythm (Dysrhythmias)
Palpitations, Irregular pulse, Dizziness or lightheadedness Syncope, Shortness of breath, Chest pain or discomfort, Fatigue or weakness, Hypotension, Decreased perfusion signs
What are some lab values that may indicate a patient is suffering from malnutrition?
Low hemoglobin
Electrolyte imbalances
Low albumin
Low prealbumin
Low total protein
An alert and competent adult patient with severe internal bleeding is informed that a blood transfusion is necessary to survive. The patient refuses the transfusion, stating they understand the risk of death. What is the nurse’s priority action?
Assess patient decision-making capacity
What are things the nurse should assess before, during, and after foley catheter removal?
Confirm order to remove
Check color, odor, output
Patient’s ability to void
Mobility and functional status
Check catheter tip
Monitor for first void within 6–8 hours
Observe for dysuria, frequency, or urgency
A nurse is caring for a client who has been on bed rest for several days following surgery. Which action should the nurse take first to safely progress the client’s activity level?
Help the client sit on the edge of the bed (dangle)
Rapid response initiation criteria
Airway & Breathing
Circulation
Neurological Changes
A nurse is planning care for a client who is receiving enteral feedings through an NG tube. Which of the following actions should the nurse plan to take first?
Aspirate the client’s stomach contents.
What is involved with post mortem care
Confirm the time of death
Provide privacy and allow family time with the body
Remove all lines and drains (unless told otherwise)
Toe tag and outside the bag patient information
A patient who recently started opioid therapy states they “haven’t had a bowel movement in several days.” The abdomen is firm with hypoactive bowel sounds. Which findings support the nurse’s analysis that the patient is experiencing opioid‑induced constipation?
Decreased bowel sounds on auscultation
A pattern of reduced bowel motility after starting medication
A nurse is teaching a client who has a non–weight-bearing injury on the right leg how to ambulate using crutches. Which gait pattern should the nurse instruct the client to use?
Three-point gait
A nurse is analyzing a client’s ECG strip. Which of the following best describes the QRS complex?
A sharp, narrow spike that represents ventricular depolarization.
A nurse is caring for a client receiving total parenteral nutrition (TPN). During the assessment, the client reports increased thirst and frequent urination. The nurse also notes dry mucous membranes and increased urine output over the past several hours. What is the interpretation?
TPN Hyperglycemia
A nurse is caring for a client with advanced cancer who is receiving chemotherapy but is also experiencing severe pain and fatigue. The provider recommends adding palliative care services. The client asks, “Does this mean I am dying?” Which response by the nurse is most appropriate?
“Palliative care helps manage your symptoms and can be provided along with your current treatment.”