Ch 55 NCLEX
The nurse caring for a patient with a urinary diversion notices mucus around the stents and in the patient's urine. The appropriate nursing intervention is to do which of the following? a) Document presence of mucus in the urine. b) Remove the urinary stents. c) Contact the physician. d) Document the separation of the mucocutaneous junction.
a) Document presence of mucus in the urine. Explanation: The nurse should document the presence of mucus in the urine as this is a normal finding in urinary diversions.
Which of the following medications may be ordered to relieve discomfort associated with a UTI? a) Phenazopyridine (Pyridium) b) Levofloxacin (Levaquin) c) Nitrofurantoin (Furadantin) d) Ciprofloxacin (Cipro)
a) Phenazopyridine (Pyridium) Explanation: Pyridium is a urinary analgesic ordered to relieve discomfort associated with UTIs. Furadantin, Cipro, and Levaquin are antibiotics.
The most common presenting objective symptoms of a UTI in older adults, especially in those with dementia, include which of the following? a) Incontinence b) Change in cognitive functioning c) Hematuria d) Back pain
b) Change in cognitive functioning Explanation: The most common objective finding is a change in cognitive functioning, especially in those with dementia, because these patients usually exhibit even more profound cognitive changes with the onset of a UTI. Incontinence, hematuria, and back pain are not the most common presenting objective symptoms.
The nurse working with a patient after an ileal conduit notices that the pouching system is leaking small amounts of urine. The appropriate nursing intervention is which of the following? a) Secure/patch it with tape. b) Change wafer and pouch. c) Empty the pouch. d) Secure/patch with barrier paste.
b) Change wafer and pouch. Explanation: Whenever the nurse notes a leaking pouching system, the nurse should change the wafer and pouch. Attempting to secure or patch the leak with tape and/or barrier paste will trap urine under the barrier or faceplate, which will compromise peristomal skin integrity. Emptying the pouch will not rectify the leaking.
Which type of incontinency refers to the involuntary loss of urine due to medications? a) Urge b) Iatrogenic c) Overflow d) Reflex
b) Iatrogenic Explanation: Iatrogenic incontinence is the involuntary loss of urine due to medications. Reflex incontinence is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder.
The nurse caring for a patient after urinary diversion surgery monitors the patient closely for peritonitis by assessing for which of the following? Select all that apply. a) Hyperactive bowel sounds b) Leukocytosis c) Abdominal distention d) Muscle flaccidity
b) Leukocytosis, c) Abdominal distention Explanation: The nurse should monitor the patient for the following signs and symptoms of peritonitis: leukocytosis, abdominal distention, absence of bowel sounds, fever, muscle rigidity, guarding, and nausea and vomiting.
A patient undergoes surgery for removing a malignant tumor, followed by a urinary diversion procedure. The nurse's postoperative plan of care should include which of the following? a) Suggest a visit to a local ostomy group. b) Maintain skin and stomal integrity. c) Show pictures and drawings of placement of the stoma. d) Determine the patient's ability to manage stoma care.
b) Maintain skin and stomal integrity. Explanation: The most important postoperative nursing management is to maintain skin and stomal integrity to avoid further complications, such as skin infections and urinary odor. Determining the patient's ability to manage stoma care, showing photographs, and suggesting a visit to a local ostomy group would be a part of the preoperative procedure.
The nurse is conducting a history and assessment related to a patient's incontinence. Which of the following should the nurse include in the assessment before beginning a bladder training program? a) Occupational history b) Medication usage c) Smoking habits d) History of allergies
b) Medication usage Explanation: It is essential to assess the patient's physical and environmental conditions before beginning a bladder training program, because the patient may not be able to reach the bathroom in time. During the bladder training program, a change in environment may be an effective suggestion for the patient. It is not so essential to assess the patient's history of allergy, occupation, and smoking habits before beginning a bladder training program.
Which of the following terms is used to refer to inflammation of the renal pelvis? a) Interstitial nephritis b) Pyelonephritis c) Cystitis d) Urethritis
b) Pyelonephritis Explanation: Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.
The nurse planning care for a male patient with overflow and stress incontinence includes preparation for which of the following? a) Intravenous urogram b) Transrectal resection c) MRI d) CT scan
b) Transrectal resection Explanation: A transrectal resection is the procedure of choice for men with overflow and stress incontinence.
The nurse is teaching a patient with recurrent urinary tract infections (UTIs) ways to decrease her risk for additional UTIs. The nurse includes which of the following? a) Void every 5 hours during the day. b) Void immediately after sexual intercourse. c) Increase intake of coffee, tea, and colas. d) Take tub baths instead of showers.
b) Void immediately after sexual intercourse. Explanation: The nurse should include that the patient should void immediately after sexual intercourse to flush the urethra, expelling contaminants. Showers are encouraged rather than tub baths because bacteria in the bath water may enter the urethra. Coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants should be avoided. The patient should be encouraged to void every 2 to 3 hours during the day and completely empty the bladder.
In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts? a) 50 mL b) 400 mL c) 100 mL d) 30 mL
c) 100 mL Explanation: Residual urine that is less than 100 mL indicates that the suprapubic catheter cannot be discontinued. If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.
Which of the following would be included in a teaching plan for a patient diagnosed with a UTI? a) Void every 4 to 6 hours. b) Use tub baths as opposed to showers. c) Drink liberal amount of fluids. d) Drink coffee or tea to increase diuresis.
c) Drink liberal amount of fluids. Explanation: Patients diagnosed with a UTI should drink liberal amounts of fluids. They should void every 2 to 3 hours. Coffee and tea are urinary irritants. The patient should shower instead of bathing in a tub because bacteria in the bath water may enter the urethra.
Which type of medication may be used in the treatment of a patient with incontinence to inhibit contraction of the bladder? a) Tricyclic antidepressants b) Estrogen hormone c) Over-the-counter decongestant d) Anticholinergic agent
d) Anticholinergic agent Explanation: Anticholinergic agents are considered first-line medications for urge incontinence. Estrogen decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. Tricyclic antidepressants decrease bladder contractions as well as increase bladder neck resistance. Stress incontinence may be treated using pseudoephedrine and phenylpropanolamine, ingredients found in over-the-counter decongestants.
The nurse is assisting in the development of a protocol for bladder retraining following removal of an indwelling catheter. Which of the following should the nurse include? a) Performing straight catheterization every 4 hours b) Encouraging voiding immediately after catheter removal c) Avoiding drinking fluids for 6 hours d) Implementing a 2- to 3-hour voiding schedule
d) Implementing a 2- to 3-hour voiding schedule Explanation: Immediately after the removal of the indwelling catheter, the patient is placed on a voiding schedule, usually 2 to 3 hours. At the given time interval, the patient is instructed to void. Immediate voiding is not usually encouraged.
Which type of incontinence refers to involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure? a) Reflex b) Overflow c) Urge d) Stress
d) Stress Explanation: Stress incontinence may occur with sneezing and coughing. Overflow incontinence refers to the involuntary loss of urine associated with overdistention of the bladder. Urge incontinence refers to involuntary loss of urine associated with urgency. Reflex incontinence refers to the involuntary loss of urine due to involuntary urethral relaxation in the absence of normal sensations.
The nurse is teaching a patient how to perform self-catheterization. Which of the following directions should the nurse include? a) The catheter is rinsed with sterile normal saline after soaking in a cleaning solution. b) The nurse uses nonsterile technique in the hospital setting. c) Peroxide is recommended for cleaning the urinary catheter. d) The catheterization should occur 4 to 6 hours and before bedtime.
d) The catheterization should occur 4 to 6 hours and before bedtime. Explanation: The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. The catheter is rinsed with tap water after soaking in a cleaning solution. Either antibacterial soap or Betadine solution is recommended for cleaning urinary catheters at home. The nurse uses sterile technique in the hospital setting.
The nurse is assisting in the preoperative planning for stoma placement in a patient scheduled for urinary diversion surgery. Where should the nurse plan for the stoma to be located? a) At the umbilicus b) At the belt line c) Away from skin folds d) Over a bony prominence
c) Away from skin folds Explanation: The nurse plans to have the stoma located away from skin folds and creases, bony prominences, the belt line, and the umbilicus. It should be located in an area where the patient can see and reach the stoma.
The nurse, in assessing a patient's newly created stoma, observes that the stoma color is now dark purple. The appropriate nursing intervention is to do which of the following? a) Remove the urinary stents. b) Contact the physician. c) Apply Karaya powder. d) Change the pouching system.
b) Contact the physician. Explanation: The appropriate nursing intervention when a newly created stoma is dark purple is to notify the physician. The physician or wound, ostomy, and continence (WOC) nurse will assess the stoma to determine if it the stoma has superficial ischemia or if it is necrotic.
The nurse is caring for an older patient whose chart reveals that the patient has a reversible cause of urinary incontinence. The nurse creates a plan of care for which of the following conditions? a) Decreased progesterone levels b) Bladder cancer c) Asthma d) Constipation
d) Constipation Explanation: Constipation is a reversible cause of urinary incontinence in the older adult. Other reversible causes include acute urinary tract infection, infection elsewhere in the body, decreased fluid intake, a change in a chronic disease pattern, and decreased estrogen levels in the menopausal woman. The other answers do not apply.
The nurse is conducting a community education program on UTIs. The nurse determines that the participants understand the teaching when they identify which of the following as a contributing factor for UTIs in older adults? a) Active lifestyle b) Low incidence of chronic illness c) Immunocompromise d) Sporadic use of antimicrobial agents
c) Immunocompromise Explanation: Factors that contribute to UTIs in older adults include immunocompromise, high incidence of chronic illness, immobility, and frequent use of antimicrobial agents.
The nurse is preparing to assess a patient's newly created stoma. Which of the following findings would the nurse include in the documentation of a healthy stoma? a) Black color b) Dry in appearance c) Pink color d) Pain
c) Pink color Explanation: Characteristics of a healthy stoma include a pink and moist appearance. It is insensitive to pain because it has no nerve endings. A black color may indicate necrosis of the stoma, which may require surgical intervention.
The nurse is conducting a community education program on urinary incontinence. The nurse determines that the participants understand the teaching when they identify which of the following as risk factors for urinary incontinence? a) Cesarean delivery b) Body mass index (BMI) of 22 c) Sedatives d) Swimming
c) Sedatives Explanation: Use of sedatives, diuretics, hypnotics, and opioids are risk factors for urinary incontinence. Additional risk factors include high-impact exercises, a BMI greater than 40, and vaginal birth delivery.
If an indwelling catheter is necessary, which of the following nursing interventions should be implemented to prevent infection? a) Using clean technique during insertion b) Placing the catheter bag on the patient's abdomen when moving the patient c) Performing meticulous perineal care daily with soap and water d) Using sterile technique to disconnect the catheter from tubing to obtain urine specimens
c) Performing meticulous perineal care daily with soap and water Explanation: Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used during insertion of a urinary bladder catheter. The nurse must maintain a closed system and use the catheter's port to obtain specimens. The catheter bag must never be placed on the patient's abdomen unless it is clamped because it may cause backflow of urine from the tubing into the bladder.
The nurse is conducting discharge teaching for a patient who was admitted with a kidney stone. The nurse includes which of the following as a measure to prevent additional kidney stones? a) Increase protein intake. b) Adhere to a low-calcium diet. c) Avoid drinking tea. d) Avoid drinking water before bedtime.
c) Avoid drinking tea. Explanation: The nurse should teach the patient to avoid tea and other oxalate-containing foods, such as spinach, strawberries, rhubarb, peanuts, and wheat bran. The patient should restrict protein intake to 60 g/day and should drink two glasses of water at bedtime. Low-calcium diets are generally not recommended.
