Elimination And Bowel/Bladder Care - NCLEX Rn

What is the priority teaching for a patient starting pelvic floor (Kegel) exercises?

Contract pelvic muscles as if stopping urine flow, then relax. This technique strengthens pelvic floor muscles, improving continence by enhancing urethral closure mechanisms.
What is the priority action if a patient reports cramping during an enema infusion?

Slow the infusion and lower the container. Reducing flow rate alleviates intestinal spasms, allowing safe continuation and effective cleansing.
Which intervention best reduces vagal stimulation during bowel care for a high-risk patient?

Avoid straining; use stool softeners and proper positioning. Minimizing Valsalva maneuver prevents bradycardia from vagal nerve activation in susceptible patients.
Which stool characteristic is most consistent with melena?

Black, tarry, foul-smelling stool. Melena results from upper GI bleeding, where digested blood produces this appearance from hemoglobin oxidation.
Which finding is the priority indication to insert a urinary catheter for acute urinary retention?

Inability to void with a distended bladder. Acute retention causes pain and potential complications like bladder damage, making catheterization essential for relief and prevention.
What is the priority nursing action for suspected fecal impaction with liquid stool seepage?

Perform a digital rectal examination. Digital exam confirms impaction, guiding safe disimpaction and preventing complications like obstruction.
What is the correct nursing action if resistance is met while inserting a urinary catheter?

Stop insertion and notify the provider. Resistance may indicate anatomical issues or spasms, requiring professional evaluation to avoid urethral damage.
Which positioning is best to promote bladder emptying for a patient who can ambulate?

Upright on a toilet or bedside commode. Upright positioning leverages gravity to facilitate complete bladder emptying and reduce residual urine.
What is oliguria in an adult based on $24$ -hour urine output?

Urine output less than $400\ \text{mL/24 hr}$ . Oliguria indicates impaired renal perfusion or function, requiring prompt assessment to prevent acute kidney injury.
What post-void residual (PVR) volume is generally considered abnormal in adults?

PVR greater than $100\ \text{mL}$ . Elevated PVR suggests urinary retention or outlet obstruction, increasing risks of infection and bladder dysfunction.
What urine output range is considered normal for most adults in $24$ hours?

$800$ to $2000\ \text{mL/24 hr}$ . This range reflects adequate hydration and renal function, balancing fluid intake and insensible losses in healthy adults.
Which action is appropriate to reduce the risk of urinary incontinence-associated dermatitis?

Provide prompt cleansing and apply moisture barrier. Regular skin care protects against moisture-induced breakdown, preventing infection and promoting healing.
What is the priority nursing action when a Foley catheter stops draining and the patient has suprapubic pain?

Check for kinks/dependent loops and ensure bag is below bladder. Obstructions like kinks or improper positioning impede gravity-dependent drainage, exacerbating retention and discomfort.
How far should the enema tip typically be inserted in an adult?

About $3$ to $4\ \text{in}$ (approximately $7.5$ to $10\ \text{cm}$ ). This depth ensures delivery past the internal anal sphincter without risking perforation.
What is the expected normal adult urine output per hour?

At least $30\ \text{mL/hr}$ . Normal kidney function in adults typically produces this minimum hourly urine volume to maintain homeostasis and eliminate waste products effectively.
What is anuria in an adult based on $24$ -hour urine output?

Urine output less than $100\ \text{mL/24 hr}$ . Anuria signifies severe renal failure or obstruction, necessitating immediate intervention to restore urine flow.
What is the best method to obtain a sterile urine specimen from an indwelling catheter?

Aspirate from the sampling port after disinfection. Accessing the port minimizes contamination risks, ensuring specimen integrity for accurate diagnostic testing.
What is the first-line nonpharmacologic intervention to prevent constipation in most adults?

Increase dietary fiber and fluids as tolerated. Fiber and fluids promote stool softening and motility, reducing straining and preventing chronic constipation.
Which action best prevents catheter-associated urinary tract infection (CAUTI) with an indwelling catheter?

Maintain a closed drainage system. A closed system prevents bacterial entry, reducing ascension into the bladder and subsequent infection.
What is the priority contraindication to administering a rectal suppository or enema?

Recent rectal surgery or severe thrombocytopenia. These conditions heighten risks of bleeding or perforation, making rectal administration unsafe.
Which assessment finding most strongly suggests a urinary tract infection in an older adult?

New onset confusion or delirium. Older adults often present with atypical symptoms like altered mental status due to systemic inflammatory responses.
What is the recommended patient position for administering a cleansing enema?

Left lateral (Sims) with right knee flexed. Sims position facilitates enema flow along the colon's natural curve, enhancing effectiveness and comfort.
Which stool characteristic is most consistent with hematochezia?

Bright red blood in or on the stool. Hematochezia indicates lower GI bleeding, with fresh blood unchanged by digestion.
What is the priority intervention to reduce urethral trauma during urinary catheter insertion?

Use sterile technique with adequate lubrication. Sterile methods and lubrication minimize friction and microbial introduction, preventing mucosal injury and infection.
What is the priority assessment to perform before intermittent straight catheterization?

Assess for bladder distention and ability to void. Pre-procedure evaluation confirms the necessity of catheterization and identifies potential complications like retention.

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