A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?

The patient is lonely and calling then nurse in under false pretenses is a way to get attention.

The patient does not recognize the physiological signals that indicate a need to void.

The patient is not drinking enough fluids to produce adequate urine output.

The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.

Answer and Explanation

The Correct Answer is D

A. The patient is lonely and calling the nurse under false pretenses. This is an inappropriate assumption. The patient may be experiencing urinary hesitancy due to anxiety, not seeking attention.

B. The patient does not recognize the physiological signals that indicate a need to void. The patient recognized the need to void but is having difficulty due to psychological factors (e.g., anxiety, privacy concerns).

C. The patient is not drinking enough fluids to produce adequate urine output. The patient felt the urge to void, meaning they do have urine in the bladder. The issue is likely related to difficulty initiating urination rather than fluid intake.

D. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. Paruresis ("shy bladder syndrome") can make it difficult to void in the presence of others due to anxiety or embarrassment.

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Correct Answer is C

Explanation

A. Sigmoid. The sigmoid colon is the last part of the intestine, where stool is more solid and formed.

B. Transverse. Stool in a transverse colostomy is semi-formed or pasty.

C. Ascending. An ascending colostomy produces very liquid stool because it is located near the beginning of the large intestine, where water absorption is minimal.

D. Descending. Stool in a descending colostomy is more solid and formed compared to the ascending and transverse colostomies.

A. Irrigating the urinary catheter with sterile water. B. Hanging the urinary drainage bag below the level of the bladder. C. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution D. Emptying the urinary drainage bag daily

Correct Answer is B

Explanation

A. Irrigating the urinary catheter with sterile water: Not routine; only done if there is obstruction or as prescribed. Frequent irrigation increases infection risk by introducing bacteria.

B. Hanging the urinary drainage bag below the level of the bladder: Prevents backflow of urine, reducing CAUTI risk. Never let the bag touch the floor.

C. Cleansing the urinary meatus 3 to 4 times daily with antiseptic solution: Unnecessary and can irritate the urethra. Routine perineal care with soap and water is enough.

D. Emptying the urinary drainage bag daily: Should be emptied at least every 8 hours or when half full, not just daily. Reduces bacterial growth and backflow.

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A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for patients with ostomies. In which ostomy location will the nurse expect very liquid stool to be present?

Correct Answer is C

Explanation

Which nursing intervention decreases the risk for CAUTI (Catheter-Associated Urinary Tract Infections)?

Correct Answer is B

Explanation

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