Chapter 37: Urinary Elimination

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. -Contact the health care provider to ask for an order for catheter discontinuation. -Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). -Perform, or allow client to perform, perineal hygiene at least once daily. -Ensure that the drainage bag is above the level of the bladder at all times. -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. Explanation: The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.

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

-Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. -Wear underwear with a cotton crotch. -Avoid clothing that is tight and restrictive on the lower half of the body. Explanation: Client education can help prevent UTI recurrence. Teaching the client about measures that promote health and decrease the severity and incidence of UTIs is a major nursing responsibility. The nurse should instruct the client to drink eight to ten 8-oz glasses (1,920 to 2,400 mL) of water daily, drink two 8-oz glasses (480 mL) of water before and after sexual intercourse, void immediately after sexual intercourse, wear underwear with a cotton crotch, and avoid clothing that is tight and restrictive on the lower half of the body. Instruction should include drying the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum, as well as taking showers instead of baths.

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. -Having blood pressure measurements in the affected arm -Getting venipuncture in the affected arm -Getting an annual influenza vaccination -Carrying heavy items including purses or luggage with the affected arm -Sleeping with the affected arm under the head or body

-Having blood pressure measurements in the affected arm -Getting venipuncture in the affected arm -Carrying heavy items including purses or luggage with the affected arm -Sleeping with the affected arm under the head or body Explanation: The nurse should educate the caregiver and client to avoid all actions that could impair circulation to the arm with the AV graft present. Decreasing blood flow to the affected arm could result in clotting of the AV graft. Blood pressure and venipuncture should not be attempted in the affected arm. The client should not sleep with the affected arm under the body or head as the weight/compression could decrease blood flow through the graft. Carrying heavy items can compress the graft and impair blood flow causing the graft to clot. Heavy purses or bags over the shoulder of the affected arm can decrease blood flow as well. A client with long-term hemodialysis needs should get an annual influenza vaccination. Discretion should be taken with where the vaccination is injected if prescribed intramuscular.

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. The client has been diagnosed with an enlarged prostate. Which should the nurse include in the client education to encourage urination? Select all that apply. -Meditate while urinating -Do Kegel exercises 3 to 5 times per day -Try double voiding -Avoid antihistamines -Do not delay urination

-Meditate while urinating -Do Kegel exercises 3 to 5 times per day -Try double voiding -Avoid antihistamines -Do not delay urination Explanation: To improve emptying of the bladder when a man has been diagnosed with an enlarged prostate, Kegel exercises 3 to 5 times per day can help with bladder control and function. Nervousness and tension cause some men to have difficulty urinating and meditation along with exercise can help to reduce stress. Double voiding, urinating and then trying to go again a few moments later can be helpful. This will help to fully empty the bladder, lessen the feeling of constantly having to urinate, and maybe save another trip to the bathroom. The client should avoid antihistamines and decongestants. These medicines tighten the muscles around the urethra, making it harder to urinate. The nurse should encourage the client to urinate when the urge presents.

The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply. -The nurse gently palpates the client's symphysis pubis. -The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. -The nurse places the scanner head on the gel or gel pad, with the directional icon on the scanner head pointed away from the client's head. -The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). -The nurse adjusts the scanner head to center the bladder image on the crossbars. -The nurse presses and holds the END button until it beeps 3 times and then reads the volume measurement on the screen.

-The nurse gently palpates the client's symphysis pubis. -The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. -The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). -The nurse adjusts the scanner head to center the bladder image on the crossbars. Explanation: To correctly use the ultrasound bladder scanner, the nurse would gently palpate the client's symphysis pubis. Palpation identifies the proper location and allows for correct placement of scanner head over the client's bladder. The nurse would place a generous amount of ultrasound gel midline on the client's abdomen. The gel is necessary to conduct the ultrasound waves for an accurate reading. The nurse would aim the scanner head toward the bladder. Failure to point the scanner in this direction will give erroneous results. The nurse would adjust the scanner head to center the bladder image on the crossbars. This step is necessary to record the most accurate results.

The nurse is caring for a client who has a history of renal failure. What is an accurate step when caring for the client's hemodialysis access?

Auscultate over the site with a stethoscope to listen for a bruit. Explanation: The nurse should auscultate over the access site with the bell of the stethoscope, listening for a bruit or vibration, and palpate over the access site, feeling for a thrill or vibration. If these are not present, the health care provider should be notified at once. An IV should not be started in the arm with the access.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls. Explanation: 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.

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?

Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet. Explanation: 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?

Check health record for provider's order. Explanation: The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after the order is confirmed.

A client could experience increased urination when using which classification of medication?

Cholinergic agents Explanation: 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 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.

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.

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

Contact the health care provider Explanation: The term pyuria refers to the presence of pus in the urine. The nurse should first contact the health care provider, as antibiotic therapy may be necessary. Encouraging fluids, instruction on wiping technique and monitoring vital signs will follow.

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?

Fasten the condom securely enough to prevent leakage without constricting blood flow. Explanation: Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1 to 2 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.

A nurse prepares a client with a recently created ileal conduit to be discharged from the hospital. Which is an expected assessment finding?

Mucus in the urine is a normal finding. Explanation: The isolated segment of small intestine continues to produce mucus (seen in the urine), as part of its normal functioning. The stoma should be dark pink to red and moist. The size of the stoma usually stabilizes within 6 to 8 weeks. Most stomas protrude 0.5 inch to 1 inch (1.25 to 2.5 cm) from the abdominal surface.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron Explanation: The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman's capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman's capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.

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?

Position the client in a supine position. Explanation: Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.

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. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional. Explanation: A clean-catch urine specimen is used to obtain a specimen that is clean in nature. The procedure is not sterile. The process requires the nurse to provide the needed education to the client. The client will begin by cleaning the area surrounding the meatus with a provided wipe. The client will void into the toilet or bedpan and discard. The client will next void into the provided specimen container. Once the specimen container is filled the client may finish voiding in the toilet or bedpan and discard. The specimen will need to be secured and submitted to the health care professional.

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?

Regular toileting routine Explanation: The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.

The health care provider requests an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position?

Sims Explanation: The Sims, or side-lying, position is especially used for clients who have limited hip mobility because it permits excellent visualization of the urinary meatus. Usually, female clients are placed in a dorsal recumbent position for catheterization, and male clients are put in a supine or semi-Fowler position.

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?

Stress Explanation: Stress incontinence is caused by pelvic floor muscle weakness or urethral hypermobility. Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contraction. Overflow incontinence occurs when the bladder muscle distends and urine is forced out. Functional incontinence occurs when a physical or psychological impairment impedes continence despite a competent urinary system.

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

The birth can cause perineal swelling. Explanation: Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period.

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?

The client drinks two glasses of water before and after sexual intercourse. Explanation: Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.

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

True Explanation: People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.

The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice?

Urinal Explanation: A urinal is the best choice to collect urine from a nonambulatory male client. If the client is on strict bed rest or confined to bed due to weakness or disability. the client must be positioned in bed in as close to an upright position as feasible. In most instances, the client is able to place and hold the urinal himself. If he is unable to do so, the nurse should hold the urinal in place while the client urinates or place the urinal and leave the client alone for a few moments. A bedpan is not the best choice for a male client who tend to prefer the bottle-like shape of the urinal, although female clients tend to prefer the shape of a bedpan. A specimen hat is for a commode. A large urine collection bag would be used with an indwelling catheter.

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?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Explanation: 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.

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?

anuria Explanation: Absence of urine for a 24-hour period reflects anuria.

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode Explanation: The client with weakness who tires easily may benefit from a bedside commode. Because the client is ambulatory, a bed pan or fracture pan is not needed. Ambulating to the regular bathroom may increase the risk for falls.

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood Explanation: A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation?

checking that the client has signed a consent form for the procedure Explanation: The client would sign a consent form for the procedure since it is invasive. This would be completed by the procedural health care provider after explaining the purpose, risks, and benefits of the procedure. The will check that this consent is signed before the procedure beings. The client does not need to have fluids withheld nor 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 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?

cloudy, foul odor Explanation: The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine. Urine is normally light yellow and clear. Dark amber urine that is strongly aromatic could indicate dehydration, but would not create the symptoms noted.

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?

dark brown, cloudy Explanation: The client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine. Other answers are incorrect.

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?

dehydration Explanation: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The symptoms are not associated with hypovolemia, balanced fluids, nor renal failure.

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?

functional Explanation: The nurse should document the client's condition as functional incontinence when the client is unable to retain urine for some time after getting an urge to void. Stress incontinence can result in the loss of small amounts of urine when intra-abdominal pressure rises. Urge incontinence is the need to void, perceived frequently with a short-lived ability to sustain control of flow. Total incontinence is the loss of urine without any identifiable pattern.

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?

intermittent urethral catheter Explanation: 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 has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a:

neurogenic bladder. Explanation: Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both.

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:

oliguria. Explanation: Oliguria is a significant decrease in urine production. Anuria is an absence or near-absence of urine output. Nocturia is nighttime awakening to void. Polyuria is greatly increased urine production.

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere Explanation: The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.

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?

stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Other types of incontinence have different causative factors.

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing?

stress incontinence Explanation: The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to giving birth. Reflex incontinence is caused by damage to motor and sensory tracts in the lower spinal cord secondary to trauma. Urge incontinence is caused by bladder irritation secondary to infection. Functional incontinence is caused by impaired mobility, impaired cognition, or an inability to communicate.

Which type of incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions?

urge Explanation: Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions.

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:

urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." Explanation: 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 providing care for an older adult admitted to the hospital with urinary retention. The client asks the nurse, "What is wrong with me?" Which is the best response by the nurse?

"As men age, the prostate enlarges over time." Explanation: Urinary retention, dribbling incontinence, and the ability to empty the bladder occur as a result of aging. In men, many of these problems are related to an enlarging prostate gland. The nurse should not indicate "I have no idea" as this is not addressing the client's question nor does it foster trust in the nurse-client relationship. Suggesting the client is not drinking enough water is inaccurate as the enlarged prostate is restricting urinary flow. In addition, such a statement may encourage the client to drink more fluids and increasing urinary retention symptoms.

The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment?

"Do you have the sensation to urinate?" Explanation: In reflex incontinence, the client empties the bladder without the sensation of the need to void. The client dribbles with overflow incontinence. In total incontinence, the client has a continuous and unpredictable loss of urine. Stress incontinence occurs when there is an increase in the intra-abdominal movements, such as coughing and straining.

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?

"Let's explore structuring activities and toileting breaks." Explanation: The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.

A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate?

"Performing Kegel exercises can help with muscle strengthening." Explanation: The client with urinary incontinence may benefit from performing Kegel exercises several times daily to help tone pelvic floor muscles. The client would want to avoid caffeine, alcohol, and artificial sweeteners, as these increase the risk of incontinence. The daily recommended fluid intake would be 1500 to 2000 mL to prevent dehydration; fluid intake may be limited at night to decrease nocturia. A Foley catheter would not be routinely placed for this, but would instead be a last resort for incontinence.

The nurse is caring for a client who informs the nurse that it is difficult to void when experiencing stress, and asks why this happens. Which response by the nurse is appropriate?

"Stress causes the muscles to become tense." Explanation: Stress can interfere with the ability to relax the perineal muscles and the external urethral sphincter. When this happens, the client may feel an urge to void, but emptying the bladder completely becomes difficult or impossible. Needing privacy to void relates back to stress from perceived embarrassment from the need to void, which enforces the proper answer of stress affecting the perineal muscles. There is not enough information present within the scenario to point to the possibility of a neurologic condition or medications taken by the client.