A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?

Polyuria

Peripheral edema

Decreased respirations

Absent bowel sounds

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Polyuria is incorrect. Peritonitis doesn’t directly influence urine output. Polyuria (increased urine production) is more commonly associated with conditions affecting the kidneys or diabetes mellitus rather than peritonitis.
Choice B Reason:
Peripheral edema is incorrect. Peritonitis typically involves abdominal symptoms and signs rather than peripheral issues like edema. Edema can be related to heart, kidney, or circulatory system problems, but it's not a typical manifestation of peritonitis.
Choice C Reason:
Decreased respirations is incorrect. Peritonitis can cause pain and discomfort, which might affect the depth of breathing or result in shallow breathing due to guarding against abdominal pain. However, decreased respirations as a specific finding wouldn't commonly be expected in peritonitis. Pain might cause shallow breathing, but it wouldn't lead to a consistent decrease in respiratory rate.
Choice D Reason:
Absent bowel sounds is correct. Peritonitis is an inflammation of the peritoneum, the lining of the abdominal cavity. This condition often leads to the loss or significant reduction of bowel sounds due to the irritation and inflammation of the abdominal structures.

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Correct Answer is B

Explanation

a.While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.

b.This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.

c.A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.

d.Removing polyps during a colonoscopy is a common procedure and does not necessarily require a separate procedure.

A. Wipe the sample port with an alcohol wipe and let the alcohol dry. B. Clamp the catheter tubing distal to the sampling port for 15 min. C. Attach a sterile needleless syringe to the sample port and aspirate the specimen D. Document in the client's electronic medical record that the specimen was sent to the laboratory. E. Empty the urine into a sterile container labeled with the client identifiers

Correct Answer is B, A, C, E, D

Explanation

Clamp the catheter tubing distal to the sampling port for 15 min. By clamping the tubing distal to the sampling port, it allows urine to accumulate in the tubing, ensuring that the urine specimen obtained is fresh and not from the stagnant urine that has been sitting in the tubing.

Wipe the sample port with an alcohol wipe and let the alcohol dry. Cleaning the sampling port with an alcohol wipe helps reduce the risk of introducing contaminants into the sample during collection, ensuring a more sterile procedure.

Attach a sterile needleless syringe to the sample port and aspirate the specimen. Using a sterile syringe prevents contamination and allows for the collection of a clean urine sample directly from the catheter tubing, maintaining the sterility of the specimen.

Empty the urine into a sterile container labeled with the client identifiers. Transferring the collected urine into a sterile container labeled with the client's identifiers ensures proper identification and handling of the specimen for laboratory analysis.

Document in the client's electronic medical record that the specimen was sent to the laboratory. Documenting in the client's medical record ensures that there is a clear record of the specimen collection, its handling, and its dispatch to the laboratory for analysis, maintaining proper documentation and continuity of care.

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A nurse is collecting data from a client who has peritonitis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who will undergo a colonoscopy the following week. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is obtaining a sterile urine specimen from a client who has an indwelling urinary catheter. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is B, A, C, E, D

Explanation

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