CH 38 Urinary elimination

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? A. "Discard your first urine and begin the collection after that." B. "Begin the collection when you first urinate in the morning." C. You will need to have a catheter inserted for this collection." D. "Start collecting the urine with the next time you urinate."

A. "Discard your first urine and begin the collection after that."

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? A. "I will use clean gloves to handle the catheter and other equipment." B. "Washing hands before and after the procedure is important." C. "The client will be placed in a reclining position with knees bent." D. "I will place a bath blanket over the client to provide privacy."

A. "I will use clean gloves to handle the catheter and other equipment." Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse.

A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training? A. "One signal of preparedness is when your child is dry for at least 2 hours." B. "Your child should be at least 2 years old before you start toilet training." C. "Girls typically take longer than boys to be ready for toilet training." D. "Your child will tell you when there is a sensation of bladder fullness."

A. "One signal of preparedness is when your child is dry for at least 2 hours." A child is typically 2 to 3 years old before beginning toilet training, although this does depend on the culture. The child signals readiness by staying dry for longer periods, usually at least 2 hours. The child may feel a sensation of bladder fullness, but may not necessarily be able to express this. Boys may take longer to be ready for toilet training than girls.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? A. Boys may take longer for daytime continence than girls. B. Daytime continence is usually not achieved by boys until age 5. C. Boys may walk by 1 year and should be continent by 3 years. D. Incontinence after the age of 3 years is not normal.

A. Boys may take longer for daytime continence than girls. Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.

A client is reporting bladder urgency. The nurse will assess which of the following? A. Caffeine intake B. Blood pressure C. Use of vitamin supplements D. Body weight

A. Caffeine intake Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts. Blood pressure changes do not typically cause urgency, nor do most common vitamin supplements. Body weight affects urinary function, as with all body systems, but is not specifically linked to urgency.

A nurse assessing an older adult client finds that the client has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause? A. Decreased bladder contractility B. Neurologic weakness C. Decreased bladder muscle tone D. Diminished ability to concentrate urine

A. Decreased bladder contractility The nurse would suspect the client has decreased bladder contractility, which leads to the client having issues with urinary retention. Diminished ability to concentrate urine would be an issue with the kidney, not the urinary tract.

A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? A. Ensure that the catheter is removed as soon as possible. B. Use clean technique when inserting the catheter.

A. Ensure that the catheter is removed as soon as possible.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? A. Having the client sign a consent form for the procedure B. Maintaining the client without liquids before the procedure C. Inserting a Foley catheter the morning of the procedure D. Explaining to the client that the procedure will be painful

A. Having the client sign a consent form for the procedure The client would sign a consent form for the procedure since it is invasive. This would be completed after the procedural health care provider had explained the purpose, risks, and benefits of the procedure. The client would not be maintained NPO (nothing by mouth) or have a catheter inserted for this procedure. The procedure is usually painless, so the client would not be told to expect pain as a normal part of the procedure.

The nurse has received an order to catheterize a female client. What action should the nurse perform? A. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm). B. Advance the catheter until slight resistance is felt. C. Lubricate 3 to 4 in of the catheter tip before insertion. D. Using both hands, hold the catheter near the tip and insert slowly into the urethra.

A. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm). The nurse should lubricate 1 to 2 in (2.5 to 5 cm) of the catheter tip and, using the dominant hand, hold the catheter 2 to 3 in (5 to 7.5 cm) from the tip and insert slowly into the urethra. The nurse should then advance the catheter until there is a return of urine (approximately 2 to 3 in [5 to 7.5 cm]) and, once urine drains, advance catheter another 2 to 3 in (5 to 7.5 cm). The nurse may encounter slight resistance when advancing the catheter, but this does not necessarily indicate correct placement; further advancement of the catheter may be necessary to obtain urine flow.

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? A. Position the client in a supine position. B. Assess the client's need for analgesia. C. Have the client rest for 15 minutes before the assessment. D. Administer a diuretic, as ordered.

A. Position the client in a supine position.

The nurse is collecting a clean-catch specimen from a client. Which nursing action is performed correctly in this procedure? A. Position the container near the meatus, and collect at least 10 mL of urine. B. Continue collecting the urine in the container until the bladder is empty. C. Collect the first 10 mL of urine voided in the sterile specimen container. D. Don sterile gloves

A. Position the container near the meatus, and collect at least 10 mL of urine.

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation? A. Prime the tubing with the solution. B. Place the sterile solution on the bed. C. Empty the balloon with a syringe. D. Clean around the urinary meatus.

A. Prime the tubing with the solution.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions? A. The client should avoid wearing tight clothes or belts near the site. B. The client may bathe rather than shower, provided the site is covered with gauze. C. Sterile technique must be observed by the client in the home setting. D. A dressing should always be worn over the site to avoid leaking.

A. The client should avoid wearing tight clothes or belts near the site.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true? A. The largest part of a regular bedpan should be placed under the client's buttocks. B. A fracture bedpan is preferred for urination and a regular bedpan is preferred for defecation. C. A regular bedpan is generally more comfortable for clients than a fracture bedpan. D. A fracture bedpan should be used only for clients who have fractures of the femur or lower spine.

A. The largest part of a regular bedpan should be placed under the client's buttocks.

The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include? A. Tighten the internal muscles used to prevent or interrupt urination. B. Perform these exercises 10 times daily for 1 month. C. Keep muscles contracted for at least 30 seconds. D. Relax muscles for at least 1 minute between contractions.

A. Tighten the internal muscles used to prevent or interrupt urination.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true? A. Unless contraindicated, nurses should encourage clients to stand to use a urinal. B. Urinals must be replaced every 24 hours to reduce the risk of infection. C. If nocturnal incontinence is anticipated, a urinal can be placed between the legs while the client is asleep. D. Both male and female clients commonly void into a urinal in the bathroom to facilitate measurement of urinary output.

A. Unless contraindicated, nurses should encourage clients to stand to use a urinal.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. The client's skin is also excoriated from urinary incontinence. Which nursing concern is most appropriate for the nurse to include in this client's car plan? A. altered skin integrity related to urinary bladder infection and dehydration B. urinary tract infection risk related to dehydration C. altered skin integrity related to functional incontinence D. urinary incontinence related to urinary tract infection

A. altered skin integrity related to urinary bladder infection and dehydration

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? A. dehydration B. balanced fluids C. kidney injury D. hypovolemia

A. dehydration

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? A. first thing in the morning B. evening C. before bedtime D. afternoon

A. first thing in the morning

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? A. intermittent urethral catheter B. Foley catheter C. retention catheter D. indwelling urethral catheter

A. intermittent urethral catheter An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted.

A client at a health care facility is being treated for cancer of the bladder. The health care provider uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion? A. one or both of the ureters are surgically implanted elsewhere B. use of a catheter to collect urine in a sterile environment C. inability to control either urinary or bowel elimination D. hygiene measures used to keep meatus and adjacent area of the catheter clean

A. one or both of the ureters are surgically implanted elsewhere

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. Dry the perineal area after urination or defecation from the back to the front. Avoid clothing that is tight and restrictive on the lower half of the body. Wear underwear with a cotton crotch. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Take baths instead of showers.

Avoid clothing that is tight and restrictive on the lower half of the body. Wear underwear with a cotton crotch. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse.

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? A. "It would be best just to get some adult diapers." B. "Let's explore structuring activities and toileting breaks." C. "Don't worry, this is a normal condition for older adults." D. "Let me refer you to a urologist who can help you

B. "Let's explore structuring activities and toileting breaks."

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? A. clean-catch specimen B. 24-hour specimen C. intermittent specimen D. random specimen

B. 24-hour specimen

For which client will the nurse plan interventions addressing a neurogenic bladder? A. A client with weak pelvic floor muscles B. A client recovering from a stroke C. A client being treated for pyelonephritis D. A four-year old child who has not successfully been toilet trained

B. A client recovering from a stroke

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action? A. Assess urine characteristics. B. Check electronic health record for medical order. C. Gather equipment and supplies. D. Explain the procedure to the client.

B. Check electronic health record for medical order.

A client could experience increased urination when using which classification of medication? A. Central nervous system depressants B. Cholinergic agents C. Stool softeners D. Analgesic medications

B. Cholinergic agents Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination. Analgesics act to relieve pain. Central nervous system depressants are medicines that include sedatives, tranquilizers, and hypnotics. These drugs can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders. Stool softeners makes bowel movements softer and easier to pass.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next? A. Place the client on either side and rescan. B. Ensure proper positioning of the scanner head and rescan. C. Have the client drink 8 ounces of water every 15 minutes for 1 hour. D. Wipe off some of the ultrasound gel and rescan

B. Ensure proper positioning of the scanner head and rescan.

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? A. Remove the catheter every 8 hours, or more often in humid weather. B. Fasten the condom securely enough to prevent leakage without constricting blood flow. C. Ensure the tip of the tubing is touching the tip of the client's penis. D. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application.

B. Fasten the condom securely enough to prevent leakage without constricting blood flow.

A client is suspected of having a disease process affecting the basic functional unit of the kidney. Which structure is most likely involved? A. Glomerulus B. Nephron C. Loop of Henle D. Bowman's capsule

B. Nephron

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority? A. Placing the client as N.P.O. status B. Notifying the health care provider of the assessment findings C. Checking for blood return in the CVC D. Obtaining laboratory studies

B. Notifying the health care provider of the assessment findings The assessment is indicative of hospital-acquired catheter infection associated with the CVC. The medical provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Checking for blood return is not indicated and access to the CVC used for hemodialysis should not be attempted without a prescription to do so from the health care provider.

A nurse is performing a client's intermittent closed catheter irrigation and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's best response to this situation? A. Prepare to change the catheter. B. Repeat the irrigation. C. Notify the primary care provider promptly. D. Wait 1 hour and repeat the irrigation.

B. Repeat the irrigation.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions? A. The client soaks in the bathtub daily for perineal care. B. The client drinks two glasses of water before and after sexual intercourse. C. The client drinks eight 8-oz glasses of cranberry juice daily. D. Since the client is symptom-free, she no longer takes the prescribed antibiotics.

B. The client drinks two glasses of water before and after sexual intercourse.

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? A. The nurse failed to deflate the retention balloon after pretesting it for integrity. B. The client has an enlarged prostate. C. The diameter of the catheter is too large. D. The client has an occult abscess in the urethra.

B. The client has an enlarged prostate.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal? A. The client has a history of benign prostatic hyperplasia (BPH; prostate enlargement). B. The client is acutely confused and has been diagnosed with delirium. C. The client was treated for kidney stones a few months earlier. D. The client has had urinary catheters in place repeatedly during previous admissions.

B. The client is acutely confused and has been diagnosed with delirium. A client who is acutely confused is likely unable to manipulate a urinal effectively. Kidney stones, BPH, and previous catheterizations do not preclude the use of a urinal.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted? A. The novice nurse asks the client to take a deep breath when resistance was met during insertion of the catheter. B. The novice nurse selects an 18 French Foley catheter to insert. C. The novice nurse assists the client to a dorsal recumbent position with knees flexed, feet about 2 ft (0.6 m) apart. D. The novice nurse places a trash receptacle within easy reach.

B. The novice nurse selects an 18 French Foley catheter to insert.

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action by the UAP is noted? A. UAP places a waterproof pad under the client's buttocks before placing bedpan. B. UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan. C. UAP places the hand closest to the client palm up, under the lower back, and assists with lifting. D. UAP applies powder to the rim of the bedpan.

B. UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan. It is important to place the bedpan in the proper position to prevent spills onto the bed, ensure client comfort, and prevent injury to the skin from a misplaced bedpan. Therefore, the UAP should position the bedpan so the client's buttocks rest on the rounded shelf of the regular bedpan. Applying powder to the rim of the bedpan helps keep the bedpan from sticking to the client's skin and makes it easier to remove, unless it is contraindicated. The nurse uses less energy when placing the hand closest to the client palm up, under the lower back, and assisting with client lifting. A waterproof pad protects the bed from bedpan spillage.

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? A. aromatic, green B. dark brown, cloudy C. reddish-brown, clear D. clear, light yellow

B. dark brown, cloudy

A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate? A. total B. functional C. urge D. reflex

B. functional

A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? A. reflex B. stress C. urge D. total

B. stress

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate? A. clear, colorless B. strongly aromatic, dark amber C. light yellow, clear D. cloudy, foul odor

B. strongly aromatic, dark amber

A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced? A. reflex B. total C. stress D. urge

B. total Total incontinence takes place without a pattern or warning, and without client control, often in the presence of altered consciousness. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? A. Administer an IV on the arm high above the access site. B. Measure the client's blood pressure on the arm above the access site. C. Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. D. Perform venipuncture below the access site to obtain a blood sample for laboratory testing.

C. Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse will perform what assessment specifically associated with the development of this condition in the older adult? A. Assessment for nausea B. Temperature assessment C. Cognitive assessment D. Assessment for dysuria

C. Cognitive assessment

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? A. Monitor vital signs B. Encourage fluids C. Contact the health care provider D. Instruct on proper wiping technique

C. Contact the health care provider

A client has been NPO (nothing by mouth) after midnight for surgery and the client has received no IV fluids. It is now 1300 and the nurse has asked the client to attempt to void before being transferred to the surgical suite. The nurse should expect the client's urine to be what color? A. Pale yellow B. Tea colored C. Dark amber D. Colorless

C. Dark amber

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem? A. Tell the client that this happens to all people when they get older. B. Inform the client that this is not normal and make a referral to a urologist. C. Discuss the use of protective undergarments to avoid embarrassment from incontinence. D. Encourage the client to confide in family members and tell them about the accidents.

C. Discuss the use of protective undergarments to avoid embarrassment from incontinence.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? A. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. B. Ask the client to bear down until the catheter is expelled. C. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. D. Remove the catheter from the vagina and attempt to insert it into the bladder.

C. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client? A. Encouraging the client to stay close to home B. Fluid restriction C. Regular toileting routine D. Indwelling catheterization

C. Regular toileting routine

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? A. Functional B. Overflow C. Stress D. Urge

C. Stress

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider? A. Respiratory rate B. Pedal pulses C. Thrill and bruit D. Temperature

C. Thrill and bruit The client is experiencing decreased circulation to the left arm that has an AV graft for hemodialysis. There is increased risk for the AV graft to clot and create a circulatory emergency. Obtaining a full set of vital signs would be indicated to evaluate overall status of the client; however, the health care provider would need to know if thrill and bruit are present over the AV graft. Absence of thrill and bruit is a medical emergency.

The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence? A. Stress incontinence B. Overflow incontinence C. Total incontinence D. Functional incontinence

C. Total incontinence Total incontinence may be the result of surgery, trauma, or physical malformation; the client has continuous and unpredictable loss of urine. Stress incontinence is related to an increase in intra-abdominal pressure and commonly occurs during activities such as coughing and sneezing. Overflow incontinence is associated with overdistention and overflow of the bladder, whereby the signal to empty the bladder is lost, the bladder fills, and the client dribbles urine. Functional incontinence occurs because the client is unable to reach the toilet.

The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed? A. Magnesium - 2.5 mEq/L (2.5 mmol/L) B. Hemoglobin - 16 g/dL C. Urine culture sensitivity - 100,000/mL D. Blood urea nitrogen (BUN) - 7 mg/dL (19.6 mmol/L)

C. Urine culture sensitivity - 100,000/mL 100,000 organisms per milliliter in a urine culture and sensitivity specimen is positive of a urinary tract infection. BUN, hemoglobin, and magnesium are all within the normal ranges.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? A. Perform hand hygiene between cleansing the woman's labia and inserting the catheter. B. Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. C. Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. D. Insert the catheter with her left hand while supporting the woman with her right hand.

C. Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately? A. Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure. B. Obtained urine specimen from urinary drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port. C. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. D. Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container.

C. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority? A. Using an appropriate measuring container B. Measuring the urine container at eye level C. Wearing gloves when handling the urine D. Noting the color and clarity of the urine

C. Wearing gloves when handling the urine

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? A. nocturia B. oliguria C. anuria D. urinary retention

C. anuria

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? A. light yellow, clear B. strongly aromatic, amber C. cloudy, foul odor D. clear, dark amber

C. cloudy, foul odor

A 57-year-old man is suffering from polyuria. What can cause polyuria? A. urinary tract infection B. renal calculi C. diabetes insipidus D. renal disease

C. diabetes insipidus Untreated diabetes insipidus can cause an increase in the formation and excretion of urine without a concurrent increase in fluid intake. Renal disease often leads to oliguria and even anuria, a decrease in urine outputs. Urinary tract infections cause an increase in frequency but not necessarily an increase in the amount of urine that is produced. Renal calculi can cause hematuria.

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? A. suprapubic catheter B. Foley catheter C. straight catheter D. indwelling urethral catheter

C. straight catheter

The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will: A. wash my hands before collecting the clean catch urine specimen." B. keep the labia spread after cleaning and during collection of the specimen." C. urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." D. use three wipes provided; one to clean each side of the urinary meatus, and one in the middle from front to back."

C. urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." The client accurately details the steps of the procedure except the nurse needs to further instruct the client that the client needs to void a small amount of urine into the toilet and then stop urination for a short time and then void around 3 to 5 mL into the cup.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. Insert the lubricated catheter into the urethra. Inflate the balloon with the correct amount of sterile saline. Discard used supplies. Advance the catheter until there is a return of urine. Clean each labial fold, then the area directly over the meatus.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. Ensure that the drainage bag is above the level of the bladder at all times. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily. Discontinue to catheter and report this to the healthcare provider.

Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily.

The nurse is caring for a hospitalized 3-year-old child. The mother expresses concern, stating, "My child was toilet trained for three months. Since being here, she is no longer toilet trained. I cannot understand this." What appropriate response would the nurse provide to the mother? A. "It is unusual for a child this age to be toilet trained." B. "Since she is wetting her underwear, she probably was not fully toilet trained yet." C. "Since she is so young, you can retrain her again when she gets home." D. "It is not unusual for children to regress when hospitalized; it should be short lived."

D. "It is not unusual for children to regress when hospitalized; it should be short lived."

Which client should the nurse monitor most closely for signs of urinary retention? A. A client receiving corticosteroids for acute inflammation B. A client who has been diagnosed with early stage Alzheimer's disease C. A client who suffered pelvic muscle damage in childbirth 6 months ago D. A client with an enlarged prostate

D. A client with an enlarged prostate

The nurse is caring for a client who has a history of acute kidney injury. What is an accurate step when caring for the client's hemodialysis access? A. If a thrill is not palpable and/or a bruit is not detectable, assess for these signs in the other arm. B. Use the affected arm if an IV must be started to avoid impairment of both arms. C. Percuss the site to feel for a thrill or vibration. D. Auscultate over the site with a stethoscope to listen for a bruit.

D. Auscultate over the site with a stethoscope to listen for a bruit.

The nurse is teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen? A. Catch the urine in the cup after cleansing the perineum. B. Catch the urine while holding the labia apart, after cleansing. Fill the specimen cup. C. Catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs. D. Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.

D. Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet. The client should first perform hand hygiene, then separate the labia minora and cleanse the perineum with commercially prepared aseptic swabs, starting in front of the urethral meatus and moving the swab toward the rectum. The client should repeat this cleansing process three times with different cotton balls or swabs, then begin to urinate while continuing to hold the labia apart. Next, the client should allow the first urine to flow into the toilet, followed by holding the specimen container under the urine stream. Then, the client should remove the specimen container, release the hand from the labia, seal the container tightly, and finish voiding. The client then performs hand hygiene again.

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action? A. Gather equipment and supplies. B. Explain the procedure to the client. C. Assess urine characteristics. D. Check health record for provider's order.

D. Check health record for provider's order.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? A. A sterile urine specimen can be obtained from the drainage bag tubing. B. The client can apply it himself with minimal supervision. C. It can be left in place for a long period of time. D. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

D. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? A. Relax muscles for at least 5 minutes between Kegels. B. Perform these exercises two times daily for a week. C. Loosen the internal muscles used to prevent or interrupt urination. D. Keep muscles contracted for at least 10 seconds.

D. Keep muscles contracted for at least 10 seconds.

A nurse assesses the urine of a client who is using a bedpan and finds that it is a dark brown color. What medication might be causing this effect? A. Amitriptyline B. Diuretics C. Phenazopyridine D. Levodopa

D. Levodopa Levodopa and injectable iron compounds can cause brown or black urine. Phenazopyridine can cause orange or orange-red urine. Amitriptyline can cause green or blue-green urine, and diuretics can lighten the color of urine to pale yellow.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? A. Calculating the flow rate of urinary output B. Palpating the client's bladder region C. Assessing PVR using a bladder scanner D. Monitoring the characteristics of the urinary output

D. Monitoring the characteristics of the urinary output

Which urinary care teaching will the nurse provide to a young adult female client? A. If you do not feel like voiding, still strain to make sure the bladder is empty. B. Wipe from the back to the front. C. Drink water more frequently in the morning and evening to facilitate hydration. D. Refrain from douching unless ordered by a health care provider.

D. Refrain from douching unless ordered by a health care provider.

The nurse is caring for a client who has been experiencing difficulty voiding in the eight hours since her vaginal birth. What information should be provided to the client? A. A neurogenic bladder results from local anesthesia B. A urinary tract infection can result from the birth process C. Catheterization is likely necessary for five to seven days D. The birth can cause perineal swelling.

D. The birth can cause perineal swelling.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client? A. Urination can be voluntarily controlled after the stoma heals from the initial surgery. B. The client will need to change the urinary pouch every 4 hours. C. This urinary diversion is only temporary. D. The client will have to wear an external appliance to collect urine.

D. The client will have to wear an external appliance to collect urine. An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice? A. Specimen hat B. Bedpan C. Large urine collection bag D. Urinal

D. Urinal

A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? A. Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. B. Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic. C. Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. D. Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique.

D. Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens and aseptic technique. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.

The client is a new client in the outpatient wellness clinic. The client reports frequent urinary incontinence of recent onset. The nurse reviews the client's list of medications. Which medication classification will the nurse review with the client to determine when the prescription was started?' A. nonsteroidal anti-inflammatory drug (NSAID) B. calcium supplement C. H2-receptor antagonist D. antihypertensive

D. antihypertensive The nurse wants to determine if the timing of the urinary incontinence correlates with the start of a medication that could promote urinary incontinence. Antihypertensives may increase urinary incontinence, because they cause more fluid to enter into the vascular system. Thus, the fluid would be excreted through the urinary system. The other medication classifications listed do not have urinary incontinence as an adverse reaction.

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should: A. stop, deflate the balloon, withdraw the catheter 0.75 to 1.5 in (2 to 4 cm), and slowly reinflate. B. deflate the balloon, withdraw the catheter, and use a smaller sized catheter. C. wait for 30 seconds, help the client to relax, and attempt inflation again. D. deflate the balloon, insert the catheter further, and slowly attempt reinflation.

D. deflate the balloon, insert the catheter further, and slowly attempt reinflation.

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence? A. urge B. total C. stress D. functional

D. functional

The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing: A. polyuria. B. nocturia. C. anuria. D. oliguria.

D. oliguria.

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? A. reflect B. urge C. total D. stress

D. stress

The nurse is caring for a client who had an arteriovenous (AV) graft surgically placed. The client is preparing for discharge. Which actions should the nurse teach the client to avoid? Select all that apply. Sleeping with the affected arm under the head or body Having blood pressure measurements in the affected arm Carrying heavy items including purses or luggage with the affected arm Getting venipuncture in the affected arm Getting an annual influenza vaccination

Having blood pressure measurements in the affected arm Getting venipuncture in the affected arm Sleeping with the affected arm under the head or body Carrying heavy items including purses or luggage with the affected arm

A nurse maintaining continuous bladder irrigation on a client notes that hourly drainage is less than amount of irrigation being given. Which interventions would be appropriate in this situation? Select all that apply. If return flow remains decreased, notify the health care provider. Check to make sure that the tubing is not kinked. Deflate and then reinflate the catheter balloon. Reposition the client in high-Fowler's position. Palpate for bladder distention. Remove the catheter.

If return flow remains decreased, notify the health care provider. Check to make sure that the tubing is not kinked. Palpate for bladder distention.

The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options. Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into toilet or bedpan. Secure the lid on the specimen container. Submit collected specimen to the health care professional. Void into the provided collection device.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into toilet or bedpan. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional

When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply. Use powder or lotion in the perineal area. Record volume and character of the urine. Encourage fluid intake, unless contraindicated. Change the indwelling catheter regularly. Maintain a closed urinary catheter system.

Record volume and character of the urine. Encourage fluid intake, unless contraindicated. Maintain a closed urinary catheter system.

Use of an indwelling urinary catheter leads to the loss of bladder tone. True False

True

A client with a new urostomy requires teaching by the nurse. The nurse will construct the plan of care and education based upon which primary nursing diagnosis? Select all that apply. risk for infection situational low self-esteem functional urinary incontinence stress urinary incontinence risk for impaired skin integrity

risk for infection risk for impaired skin integrity situational low self-esteem