Nokea
____ is the inability to control urine or bowel elimination and can be a psychologically distressing and socially disruptive problem especially among older adults.
Correct Answer: Incontinence
Rationale: Incontinence is the inability to control urine or bowel elimination. It can be a psychologically distressing and socially disruptive problem, especially among older adults.
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A ____ is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
Correct Answer: urostomy
Rationale: A urostomy is the diversion of urine away from a diseased or defective bladder through a surgically created opening or stoma in the skin.
Bladder training is initiated on a patient preparing for discharge to home from an acute care setting. When should voiding times be scheduled?
- A. At least every hour
- B. At patients request
- C. Before each meal
- D. At bedtime
- E. Upon waking up in morning
Correct Answer: C,D,E
Rationale: Typical voiding times are upon rising, before each meal, and at bedtime. When initiating bladder training the nurse should assist the patient to void as scheduled, check the patient for wetness periodically, and remind or assist the patient to the toilet as scheduled.
During insertion of a Foley catheter the patient grimaces as the balloon is inflated. What is the immediate reaction of the nurse?
- A. Withdraw the catheter.
- B. Ask the patient to bear down.
- C. Continue to inflate the balloon.
- D. Advance the catheter into the bladder.
Correct Answer: D
Rationale: Grimacing is a sign of pain indicating that the balloon might be in the urethra instead of the bladder. The catheter should be advanced before inflation.
What would be the correct explanation of catheter care?
- A. Cleansing the first 2 in of the catheter with soap and water every shift
- B. Disinfecting the entire catheter with alcohol every shift
- C. Lubricating the catheter with antiseptic lotion every 24 hours
- D. Cleansing the meatal-catheter junction every 24 hours
Correct Answer: A
Rationale: The first 2 in of the catheter should be cleaned with soap and water every shift or more often if the patient is incontinent. Alcohol and lotions are contraindicated. Catheter care should be done every shift.
Before inserting a nasogastric tube what measurement should the nurse take?
- A. Tip of the nose to the earlobe to the xiphoid process
- B. Bridge of the nose to the xiphoid process
- C. Nose to the top of the ear to the stomach
- D. Clavicular notch to the stomach
Correct Answer: A
Rationale: The measurement is from the tip of the nose to the ear lobe to the xiphoid process.