Fundamentals of Success Urinary Elimination
A nurse must obtain a urine specimen for a culture and sensitivity test from a client who has an indwelling urinary catheter. Place the following steps in the order in which they should be performed. 1. Wash your hands and don clean gloves. 2. Remove the clamp from the drainage tubing. 3. Drain the urine in the tubing into the drainage bag. 4. Clamp the drainage tubing below the specimen port for 15 to 30 minutes. 5. Swab the specimen port with an antiseptic and aspirate urine via a sterile syringe. 6. Transfer the urine to a sterile specimen cup and discard the syringe into a sharps container.
Answer: 3, 4, 1, 5, 6, 2 Rationale: 1. Washing the hands limits the number of microorganisms on the hands. Clean gloves protect the nurse from the client's body fluids. Both practices are part of standard precautions. 2. Removing the clamp from the drainage tubing reestablishes the flow of urine from the client to the drainage bag. If it is left clamped, urine will not drain, causing bladder distention, and may precipitate a stasis-induced urinary tract infection. 3. Draining the urine ensures that previously produced urine is not collected for a current specimen. 4. Clamping the drainage tubing allows urine to collect above the specimen port. 5. The use of an antiseptic swab removes microorganisms on the specimen port, and sterile equipment maintains the sterility of the closed urinary drainage system. 6. The sterility of the specimen must be maintained to prevent contamination of the specimen, which can result in inaccurate results Discarding the used syringe in a sharps container prevents accidental injury to self or others.
A primary health-care provider prescribes a bladder ultrasound scan to be performed after a client voids to determine the amount of residual urine. The nurse explains the test to the client. Place the following steps in the order that they should be performed by the nurse. 1. Clean the client's abdomen to remove the gel and clean the scan head with isopropyl alcohol. 2. Put 5 mL of conducting gel on the client's symphysis pubis and place the scan head on the gel. 3. Aim the scan head toward the client's coccyx and press the scan head button. 4. Drape the client, exposing only the lower abdomen and suprapubic area. 5. Obtain the bladder volume and repeat the measurement several times. 6. Place the client in the supine position.
Answer: 6, 4, 2, 3, 5, 1 Rationale: 1. Removing the gel and washing the client's abdomen promote hygiene and comfort. Cleaning the scan head removes the gel on the end of the probe. 2. The use of conducting gel or an ultrasound gel pad improves transmission of the ultrasound image. 3. The scan head should be placed approximately 1.5 inches (4 cm) above the pubic bone midline below the umbilicus (symphysis pubis) while aiming the scan head toward the coccyx. This permits visualization of the urinary bladder. In women, the bladder lies in front of and below the uterus. In men, the bladder can be partly obstructed by the pubic bone, and the scan head may require a slightly oblique angle to visualize the bladder. 4. Draping the client an exposing just the lower abdomen and suprapubic area provide for client privacy. 5. Several measurements should be obtained to ensure accuracy of the results. 6. The supine position permits access to the client's lower abdomen and suprapubic area.
A confused client is incontinent of urine and stool and smears the stool on the bed linens and bed rails. Which should be the initial client goal? A. The client will be clean and dry continuously. B. The client will become continent within a week. C. The client will stop soiling the environment immediately. D. The client will call for the bedpan whenever the urge to eliminate occurs.
Answer: A Rationale: A. A client's basic physical needs should be given first priority. As soon as a client is incontinent of either urine or stool, the client should receive perineal care. Remaining "continuously" clean and dry meets the criterion of a time frame when writing a goal. B. The client may not have the physical, mental, or emotional ability to achieve the goal of becoming continent. C. The client may not have the physical, mental, or emotional ability to achieve the goal of continence and stop soiling the environment. D. The client may not have the physical or cognitive ability to achieve the goal of calling for a bedpan.
A primary health-care provider prescribes a urine specimen for culture and sensitivity via a straight catheter for a client. Which should the nurse do when collecting this urine specimen? A. Use a sterile specimen container. B. Collect urine from the catheter port. C. Inflate the balloon with sterile water. D. Have the client void before collecting the specimen.
Answer: A Rationale: A. A culture attempts to identify the microorganisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against the isolated microorganisms. A sterile specimen container is sued to prevent contamination of the specimen by microorganisms outside the body. B. The urine from a straight catheter (single-lumen tube) flows directly into the specimen container. Collecting a urine specimen from a catheter port is necessary when the client has a urinary retention catheter. C. A straight catheter has a single lumen for draining urine from the bladder. A straight catheter does not remain in the bladder and therefore does not have a second lumen for water to be inserted into a balloon. D. Having the client void before collecting the specimen may result in no urine left in the bladder for the straight catheter to collect. A minimum of 3 mL of urine is necessary for a specimen for urine culture and sensitivity.
A client has urinary incontinence. Which is the best nursing intervention for this client? A. Providing skin care immediately after soiling B. Using a deodorant soap when providing skin care C. Drying the area well after providing perineal care D. Dusting the perineal area with a light film of cornstarch
Answer: A Rationale: A. As soon as possible after an incontinence episode, the client should receive thorough perineal care with soap and water, and the area should be dried well. This action removes urea from the skin, which can contribute to skin breakdown. B. Plain soap, not deodorant soap, is all that is necessary when providing perineal care after urinary or bowel incontinence. C. Although drying the area well after providing perineal care is done, it is not the best intervention of the options offered. D. Dusting the perineal area with cornstarch should be avoided. Cornstarch can accumulate in folds of the skin and, when damp, can become like sandpaper, causing friction upon movement and then skin breakdown.
Which clinical manifestation can a nurse expect when a postoperative client experiences stress associated with surgery? A. Decreased urinary output B. Low specific gravity C. Reflex incontinence D. Urinary hesitancy
Answer: A Rationale: A. During surgery, because of the effects of the general adaptation syndrome, the posterior pituitary secretes antidiuretic hormone (ADH) that promotes water reabsorption in the kidney tubules. Also, the anterior pituitary secretes adrenocorticotropic hormone that stimulates the adrenal cortex to secrete aldosterone, which reabsorbs sodium and thus water. B. A low specific gravity reflects dilute urine. With the stress response, urine will be concentrated and specific gravity will be elevated. C. The stress response is unrelated to reflex incontinence. Reflex incontinence is a predictable, involuntary loss of urine with no sensation of urgency, the need to void, or bladder fullness. D. The stress response is unrelated to urinary hesitancy. Hesitancy is the involuntary delay in initiating urination.
Which information about a client is communicated when a nurse documents that the client has polyuria? A. Excreting excessive amounts of urine B. Experiencing pain on urination C. Retaining urine in the bladder D. Passing blood in the urine
Answer: A Rationale: A. Polyuria is an excessive output of urine. This is associated with problems such as diabetes mellitus, diabetes insipidus, the acute (diuresis) phase after a burn injury, and reduced levels of ADH. B. Pain on urination is the description of dysuria, not polyuria. C. Retaining urine in the bladder is the description of urinary retention, not polyuria. D. Passing blood in the urine is the description of hematuria, not polyuria.
A nurse is caring for a group of clients with a variety of urinary problems. Which physical response identified by the nurse should cause the most concern? A. Anuria B. Dysuria C. Diuresis D. Enuresis
Answer: A Rationale: A. The inability to produce urine (anuria) is a life-threatening situation. If the cause is not corrected, the client will need dialysis to correct fluid and electrolyte imbalances and rid the body of the waste products of metabolism. B. Although dysuria is a concern because it may indicate a urinary tract infection, it is not as serious as a response in another option. C. The secretion and excretion of large amounts of urine (diuresis) are a concern, but they are not as serious as a response in another option. D. Involuntary discharge of urine after an age when bladder control should be established (enuresis) is a concern, but it is not as serious as a response in another option.
Client reports burning on urination. Which question should the nurse ask to best obtain information about the client's dysuria? A. "Can you tell me about the problems you are having with urination?" B. "How would you describe your experience with incontinence?" C. "What are your usual bowel habits?" D. "What color is your urine?"
Answer: A Rationale: A. This open-ended question encourages the client to talk about the problem from a personal perspective. Follow-up questions can be more specific. B. Dysuria is not necessarily related to incontinence. C. Dysuria is a problem associated with urine, not fecal, elimination. D. Although an abnormal color of urine may indicate a potential urinary tract infection, which is associated with dysuria, the question is too narrow because it focuses on only one issue.
A nurse is caring for a client with a condom catheter. Which of the following is important to implement? Select all that apply. A. Avoiding kinks in the collection tubing B. Providing perineal care at least once a day C. Confirming that the adhesive band is not too tight D. Leaving 1 inch between the glans penis and drainage tubing E. Ensuring that the foreskin is over the glans penis before the catheter is applied
Answer: A, B, C, D, E Rationale: A. Avoiding kinks in the tubing is essential so that urine flows unimpeded to the urine collection bag. B. Perineal hygiene should be performed at least once a day, after a bowel movement, and whenever the catheter is changed or replaced. C. The anchoring device (e.g., adhesive band, elastic strip, or inflatable ring) must be snug enough to prevent the condom from falling off but not so tight that it interferes with blood circulation to the penis. D. Placing the condom over and beyond the glans penis and leaving 1 inch between the glans penis and drainage tubing prevents pressure against the glans penis that could cause excoriation and skin trauma. E. The foreskin should be over the glans penis. If the foreskin is left in the retracted position, it can constrict the penis, resulting in edema and tissue injury.
Which should the nurse implement to facilitate bladder continence for a male client who is cognitively impaired? Select all that apply. A. Offer toileting reminders every 2 hours. B. Apply a condom catheter in the morning. C. Provide clothing that is easy to manipulate. D. Encourage avoidance of fluids between meals. E. Explain the need to call for help with toileting every 4 hours.
Answer: A, C Rationale: A. A cognitively impaired person may not be able to receive, interpret, or respond to cues for voiding. Reminding the person to void every 2 hours results in emptying of the bladder, which may limit episodes of incontinence. B. Applying a condom catheter in the morning is unnecessary and intrusive. Also, it may create a safety issues because the client's mobility may be impaired by the tubing and urine drainage bag. C. Cognitively impaired individuals may have problems handling clothing, particularly when attempting to respond to the urge to void. Clothing that is easy to manipulate, such as articles with elastic waistbands and zippers, will facilitate undressing and dressing to void. D. Restriction of fluid intake is an inappropriate way to manage urinary incontinence. The body needs fluids throughout the day to maintain renal perfusion, kidney function, and fluid balance. E. Toileting every 4 hours is too long a time to wait between opportunities to void and usually will result in an episode of incontinence. Also, a cognitively impaired individual may not understand cause and effect or be able to follow directions.
A nurse must measure the intake and output (I&O) of a client who has a urinary retention catheter. Which equipment is most appropriate to use to measure urine output from a urinary retention catheter accurately? A. Urinal B. Graduate C. Large syringe D. Urine collection bag
Answer: B Rationale: A. Although urinals have volume markings on the side, usually they occur in 100-mL increments that do not promote accurate measurements. B. A graduate is a collection container with volume markers (usually at 25-mL increments) that promote accurate measurements of urine volume. C. Using a large syringe is impractical. A large syringe is used to obtain a sterile specimen from a retention catheter (Foley catheter). D. A urine collection bag is flexible and balloons outward as urine collects. In addition, the volume markings are at 100-mL increments that do not promote accurate measurements.
Which clinical manifestation identified by the nurse commonly is associated with excessive production of antidiuretic hormone (ADH)? A. Diuresis B. Oliguria C. Retention D. Incontinence
Answer: B Rationale: A. Diuresis occurs when there is inadequate ADH. B. ADH increases the reabsorption of water by the kidney tubules, thus decreasing the amount of urine formed. Oliguria is diminished urinary output relative to intake (less than 400 mL in 24 hours). C. With urinary retention, urine is formed, but it accumulates in the bladder and is not excreted. D. ADH is unrelated to incontinence.
A nurse reviews the results of a client's urinalysis. Which constituent found in urine indicates the presence of an abnormality that should be reported to the primary health-care provider? A. Electrolytes B. Protein C. Water D. Urea
Answer: B Rationale: A. Electrolytes are usual constituents of urine, and they fluctuate to help maintain fluid, electrolyte, and acid-base balance. B. The presence of protein in the urine indicates that the glomeruli have become too permeable, which occurs with kidney disease. Most plasma proteins are too large to move out of the glomeruli, and the small proteins that enter the filtrate are reabsorbed by pinocytosis. C. Urine usually is composed of 95% water. D. Urea is an expected constituent of urine. It is formed by liver cells when excess amino acids are broken down (deaminated) to be used for energy production.
A client has a urinary retention catheter. Which is most important when the nurse cares for this client? A. Applying an antimicrobial agent to the urinary meatus 2 times a day B. Ensuring that the catheter remains connected to the collection bag C. Wearing sterile gloves when accessing the specimen port D. Increasing fluid intake to 3,000 mL a day
Answer: B Rationale: A. Research demonstrates that cleansing the urinary meatus with soap and water daily is adequate to prevent an infection. An antimicrobial ointment provides no additional benefit. Also, it requires a prescription. B. Maintaining the connection of the catheter to the collection bag prevents the introduction of microorganisms that can cause infection. A urinary retention catheter is a closed system that should remain closed. C. Clean, not sterile, gloves should be worn. Surgical asepsis (use of a sterile syringe and alcohol swab) is necessary when accessing the specimen port on a urinary retention catheter. D. Although increasing fluid intake will increase urinary output, thereby flushing the bladder of microorganisms, it is not as important as another option.
A client's urine is cloudy, is amber, and has an unpleasant odor. Which problem may this information indicate that requires the nurse to make a focused assessment? A. Urinary retention B. Urinary tract infection C. Ketone bodies in the urine D. High urinary calcium level
Answer: B Rationale: A. The clinical manifestations indicated in the question do not reflect urinary retention. Urinary retention is evidenced by suprapubic distention and lack of voiding or small, frequent voidings (overflow incontinence). B. The urine appears concentrated (amber) and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria). C. The clinical manifestations indicated in the question do not reflect ketone bodies in the urine. A reagent strip dipped in urine will measure the presence of ketone bodies. D. The clinical manifestations indicated in the question do not reflect excessive calcium in the urine. Urine calcium levels are measured by assessing a 24-hour urine specimen.
A nurse is caring for two clients. One client has reflex incontinence and the other has total incontinence. Which characteristic is common to both reflex incontinence and total incontinence? A. Small loss of urine after an increase in intra-abdominal pressure B. Loss of urine without awareness of bladder fullness C. Retention of urine with intermittent urine overflow D. Strong, sudden desire to pass urine
Answer: B Rationale: A. Urination after an increase in intra-abdominal pressure is unrelated to both reflex and total incontinence. Urination after an increase in intra-abdominal pressure is related to stress incontinence, which is an immediate involuntary loss of a small volume of urine during an increase in intra-abdominal pressure. B. Involuntary voiding and a alack of awareness of bladder distention are related directly to both reflex incontinence and total incontinence. Reflex incontinence is the predictable, involuntary loss of urine with no sensation of urgency, the need to void, or bladder fullness. Total incontinence is the continuous unpredictable loss of urine without distention or awareness of bladder fullness. C. Retention of urine with overflow incontinence is related to urinary retention, which is the chronic inability to void followed by involuntary voiding (overflow incontinence). D. A strong, sudden desire to void is related to urge incontinence, which is an involuntary loss of urine associated with a strong, sudden desire to void.
Which should the nurse teach the client to avoid that will help prevent urinary diuresis? Select all that apply. A. Narcotics B. Caffeine C. Activity D. Alcohol E. Protein
Answer: B, D Rationale: A. Narcotics are central nervous system depressants that can cause urinary retention, not diuresis. B. Drinks with caffeine (e.g., coffee, tea, and some carbonated beverages) promote the secretion and excretion of increased amounts of urine. This may be related to the inhibition of phosphodiesterases or antagonism of adenosine receptors (or both). Antagonism of adenosine receptors inhibits proximal tubular reabsorption, resulting in an increased urine output. C. Although activity increases renal perfusion, which may increase urinary output, the increased fluid lost during activity usually is through insensible losses (e.g., perspiration, moisture in exhaled breaths). D. Alcohol limits the production of vasopressin, a hormone that tells the kidneys to reabsorb water. Urine output increases because fluid is not reabsorbed in the kidneys. E. Avoiding protein does not prevent diuresis. The presence of protein in the urine indicates that the glomeruli have become too permeable, which occurs in kidney disease. Most plasma proteins are too large to move out of the glomeruli, and the small proteins that enter the filtrate are reabsorbed by pinocytosis.
A nurse is caring for a debilitated female client with nocturia. Which nursing intervention is the priority when planning to meet this client's needs? A. Encouraging the use of bladder training exercises B. Providing assistance with toileting every 4 hours C. Positioning a bedside commode near the bed D. Teaching the avoidance of fluids after 5 p.m.
Answer: C Rationale: A. Although encouraging the use of bladder training exercises should be done, it is not the priority. B. Toileting the client every 4 hours may be too often or not often enough for the client. Care should be individualized for the client. C. The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on a commode uses gravity to empty the bladder fully and thus prevents urinary stasis. D. Fluids may be decreased during the last 2 hours before bedtime, but they should not be avoided completely after 5 p.m. Some fluid intake is necessary for adequate renal perfusion.
Which assessment is not related to monitoring both urine and stool? A. Constituents B. Urgency C. Shape D. Color
Answer: C Rationale: A. Both urine and stool have usual constituents. Urine has organic constituents (e.g., urea, uric acid, and creatinine) and inorganic constituents (e.g., ammonia, sodium, chloride, potassium, and calcium). Feces have waste residues of digestion (e.g., bile, intestinal secretions, and bacteria) and inorganic constituents (e.g., calcium and phosphorus). B. A person can feel an overwhelming need to void as well as defecate. C. Only stool can be assessed regarding shape. Stool usually is tubular in shape. Urine is a liquid that assumes the shape of the container in which it is collected. D. Both urine and stool can be assessed for color. Stool usually is brown and urine usually is yellow, straw-colored, or amber, depending on its concentration.
A nurse identifies that the client has overflow incontinence. Which factor contributes to this clinical manifestation? A. Coughing B. Mobility deficits C. Prostate enlargement D. Urinary tract infection
Answer: C Rationale: A. Coughing, which raises the intra-abdominal pressure, is related to stress incontinence, not overflow incontinence. B. Mobility deficits, such as spinal cord injuries, are related to reflex incontinence, not overflow incontinence. C. An enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25 to 60 mL) of urine to escape (overflow incontinence). D. Urinary tract infections are related to urge incontinence, not overflow incontinence.
An older adult with an indwelling urinary catheter is receiving 75 mL of 0.9% sodium chloride hourly. The client has had several hospital admissions in the last year for dehydration. The nurse is concerned about the client's renal function. What is the best intervention by the nurse to assess this client's renal functioning? A. Inspect the client's dependent areas for signs of edema. B. Calculate the client's intake and output every shift. C. Monitor the client's urine output hourly. D. Obtain the client's weight daily.
Answer: C Rationale: A. Dependent edema is more of a reflection of cardiac output. Edema associated with renal disease usually is generalized rather than localized in dependent areas. B. A shift generally is 8 to 12 hours long. A period of 8 to 12 hours is too long a time to wait to collect information. C. The kidneys should produce more than 30 mL/hour. The client has an indwelling urinary catheter that facilitates the assessment of urine output hourly. Clients without an indwelling urinary catheter should void a minimum of 240 mL of urine in 8 hours. D. Daily weights effectively monitor a client's fluid balance because 1 L of retained fluid weighs 2.2 pounds. However, a 24-hour period is too long a time to wait to collect information.
A nurse is inserting an indwelling urinary catheter into a male client. The nurse feels firm resistance while inserting the urinary catheter through the penis. What should the nurse do? A. Lower the penis until it is parallel to the length of the body. B. Inflate the balloon of the catheter with 10 mL of normal saline. C. Stop the procedure and notify the health-care provider about the resistance. D. Use a twisting motion and firmly advance the catheter 2 inches farther into the penis.
Answer: C Rationale: A. Lowering the penis until it is parallel to the length of the body will increase the trauma to the mucous membranes of the urinary tract because placing the penis parallel to the length of the body will create a 90-degree angle in the urethra where the shaft of the penis meets the abdominal wall. The penis should be held perpendicular to the client's body during catheter insertion. B. Inflating the balloon of the catheter in this situation will traumatize the urethra and inflict pain. The balloon is inflated once urine flows, and the catheter is advanced another 1 to 2 inches to ensure that it is completely inside the urinary bladder and not the urethra. C. Resistance indicates that there may be a blockage in the urethra (e.g., enlarged prostate, tumor). The procedure should be discontinued when firm resistance is felt, to prevent trauma to the urinary system. The event should be documented in the client's clinical record and the primary health-care provider notified. D. Using force or a twisting motion while advancing the catheter is contraindicated because it can traumatize the structures and mucous membranes of the urinary tract.
A client is admitted to the emergency department because of hypertension and oliguria. For which additional clinical manifestation associated with this cluster of information should the nurse assess the client? A. Thirst B. Retention C. Weight gain D. Urinary hesitancy
Answer: C Rationale: A. Thirst is associated with dehydration, not hypertension and oliguria. B. Urinary retention is unrelated to hypertension and oliguria. Urinary retention is the inability to empty the bladder. It is caused by urethral obstruction, lesions involving the nerve pathways to and from the bladder or involving reflex centers in the brain or spinal cord, and medications. Urine is retained in the bladder when high urethral pressure inhibits complete emptying of the bladder or until increased abdominal pressure causes urine to be lost involuntarily. C. Oliguria is the inability to produce more than 400 to 500 mL of urine daily. Expected daily urinary output is 1,000 to 3,000 mL, depending on the volume of fluid intake. If urine is not being produced in the presence of an average daily intake of 2,500 mL of fluid, then fluid will be retained and reflected in a gain in weight. One liter of fluid weighs 2.2 pounds. Excess fluid contributes to an increase in circulating blood volume, causing hypertension. D. Urinary hesitancy is an involuntary delay in initiating urination and is unrelated to hypertension and oliguria. It often is related to an enlarged prostate gland.
A nurse is performing a physical assessment on a newly admitted client who is experiencing urinary incontinence. Which problem identified by the nurse is often associated with this problem? A. Chronic pain B. Reduced fluid intake C. Disturbed self-esteem D. Insufficient knowledge
Answer: C Rationale: A. Urinary incontinence usually is not related to chronic pain. Chronic pain is the state in which an individual experiences pain that is persistent or intermittent and lasts for longer than 6 months. B. Reduced fluid intake is unrelated to urinary incontinence. A reduced fluid intake places an individual at risk of experiencing vascular, interstitial, or intracellular dehydration. C. Disturbed self-esteem is the state in which an individual experiences, or is at risk of experiencing, negative self-evaluation about self or capabilities. Incontinence may be viewed by a client as regressing to childlike behavior and has a negative impact on feelings about the self. D. Urinary incontinence may be unpreventable and uncontrollable. Sufficient knowledge may not prevent or promote continence. Insufficient knowledge is a state in which an individual experiences a deficiency in cognitive information or psychomotor skills, concerning a condition or treatment plan.
When the nurse is planning nursing care, which factor in the client's history places the client at risk for stress incontinence? Select all that apply. A. Lumbar spinal cord injury B. Urinary obstruction C. Six vaginal births D. Menopause E. Obesity
Answer: C, D, E Rationale: A. A person with a spinal cord injury will experience reflex incontinence, not stress incontinence. B. A person with a urinary tract obstruction will experience urinary retention, not stress incontinence. C. Stress incontinence is an immediate, involuntary loss of urine during an increase in intra-abdominal pressure. It is associated with weak pelvic muscles and structural supports resulting from multiple pregnancies, age-related degenerative changes, and overdistention between voiding. D. Older women experience a weakening of the muscles surrounding the urinary and reproductive systems because of decreasing levels of estrogen associated with menopause. E. The relationship of obesity and stress incontinence is theorized to be that excess weigh increases abdominal pressure. This, in turn, increases bladder pressure and mobility of the urethra. In addition, obesity may lead to chronic strain, stretching, and weakening of the nerves and muscles of the pelvic area.
A primary health-care provider discusses the need for a cystoscopy with a client. Which is most important for the nurse to do when caring for this client before the cystoscopy? A. Monitor the client's I&O. B. Assess the client's urine routinely. C. Encourage the client to increase the intake of oral fluids. D. Have the client sign an informed consent form before the procedure.
Answer: D Rationale: A. Although monitoring the client's I&O may be done, it is not the priority when a cystoscopy is scheduled. B. Although assessing the client's urine routinely should be done, it is not the priority before the procedure. The amount and color of urine are assessed after the procedure. Pink urine after a cystoscopy is common because of slight bleeding from irritation of the mucous membranes of the urinary tract. C. Although encouraging the intake of oral fluid before and after the procedure should be done, it is not the most important thing a nurse should do when a cystoscopy is scheduled. Keeping the client well hydrated ensures that adequate intravascular fluid will pass through the kidneys, facilitating the production and passage of urine. D. During a cystoscopy, a fiberoptic instrument is inserted through the urethra and into the bladder. It is an invasive procedure that requires the client's written permission. The primary health-care provider's discussion with the client includes the purpose of the procedure, its risks and benefits, and alternatives.
A nurse is assessing the urinary status of a client. Which sign indicates that additional nursing assessments are necessary? A. Aromatic odor B. Pale yellow urine C. Output of 50 mL hourly D. Specific gravity of 1.035
Answer: D Rationale: A. An aromatic odor is the usual odor of urine. B. Urine usually is pale yellow, straw-colored, or amber, depending on its concentration. C. Adequate renal perfusion and kidney function are reflected by an hourly urine output of 30 mL or more of urine. D. Specific gravity is the measure of the concentration of dissolved solids in the urine. The expected range is 1.001 to 1.029. A specific gravity of 1.035 indicates concentrated urine.
A client tells the nurse, "I have to urinate as soon as I get the urge to go." For which contributing factor to urinary urgency should the nurse implement a focused assessment? A. Anesthesia B. Dehydration C. Full bladder D. Urinary tract infection
Answer: D Rationale: A. Anesthesia is a central nervous system depressant that tends to cause urinary retention, not urgency. B. Dehydration causes a decrease in renal perfusion resulting in a diminished capacity to form urine (oliguria), not urgency. C. The urinary bladder does not have to be full to precipitate the urge to void. The urge to void can be felt when 150 to 200 mL of urine collects and stimulates the trigone of the urinary bladder. D. Feeling the need to void immediately (urgency) occurs most often when the urinary bladder is irritated. In the adult, the usual bladder capacity is 400 to 600 mL of urine, although the desire to urinate can be sensed when it contains as little as 150 to 200 mL. As the volume increases, the bladder wall stretches, sending sensory messages to the sacral spinal cord and parasympathetic impulses stimulate the detrusor muscle to contract rhythmically. Bladder contractions precipitate nerve impulses that travel up the spinal cord to the pons and cerebral cortex, where the person experiences a conscious need to void.
A client is experience bladder irritability. Which fluid should the nurse teach the client to include in the diet? A. Beer B. Coffee C. Orange juice D. Cranberry juice
Answer: D Rationale: A. Beer contains alcohol, which is irritating to the bladder. B. Coffee contains caffeine, which is irritating to the bladder. C. Orange juice, a citrus fruit, is irritating to the bladder. Citrus fruits are acidic. D. Cranberries have no constituents that irritate the bladder. In addition, they produce a more acidic environment that is less conducive to the growth of microorganisms and prevents bacteria from adhering to the mucous membranes of the urinary tract, thus promoting bacterial excretion.
A nurse must obtain a clean-catch urine specimen from one client and a urine specimen via a straight catheterization from another. Which intervention is not performed for both when obtaining these specimens? A. Cleanse around the urinary meatus with antiseptic swabs. B. Send the specimen to the laboratory immediately. C. Use a sterile cup to collect the specimen. D. Wear sterile gloves during the procedure.
Answer: D Rationale: A. Both tests require the area around the urinary meatus to be swiped several times with an antiseptic solution. This limits the presence of microorganisms that can contaminate the urine specimen, thus preventing inaccurate test results. B. Both urine specimens should be sent to the laboratory immediately to prevent deterioration of the specimen that could result in inaccurate results. Casts in the urine will break down if urine is not tested for an extended time. C. A sterile cup maintains the sterility of the specimen, a requirement of both tests. D. Sterile gloves must be worn when obtaining a urine specimen via a catheter. The nurse's hands touch the client and catheter tubing, which must remain sterile. Clean, rather than sterile, gloves are worn when obtaining a clean-catch urine specimen. Urine flowing out of the client is collected midstream into a sterile specimen cup.
A client returns from the surgical unit after a transurethral resection of the prostate gland. The nurse reviews the primary health-care provider's prescriptions, obtains the client's vital signs, and performs a focused client assessment. Which is the best intervention by the nurse? CLIENT'S CLINICAL RECORD Primary Health-Care Provider's Prescriptions - Regular diet - Vital signs every 4 hours - IV morphine via PCA pump: basal rate 1.5 mg/hour; PCA dose 1 mg; lockout interval 12 minutes; maximum dose over 4 hours, 26 mg - IVF: 0.9% sodium chloride 125 mL/hour - Docusate sodium 100 mg PO once daily - Out of bed to chair in p.m., ambulate twice a day - Continuous compression devices to lower extremities when in bed - Continuous bladder irrigation 0.9% sodium chloride to run at rate to keep output pink Client's Vital Signs - Temperature: 100.2F, oral - Pulse: 88 beats per minute - Respirations: 20 breaths per minute - Blood pressure: 136/80 mm Hg Focused Physical Assessment - IVF: 0.9% sodium chloride at 125 mL/hour, insertion site right forearm with no signs of infiltration or infection. Continuous compression devices in place. Pedal pulses palpable, toes pink and warm to touch. Client reporting abdominal pain of 2 on scale of 0 to 10 with occasional severe abdominal cramps. CBI in progress at 150 mL per hour. - Urinary drainage is light red with numerous clots A. Discontinue the continuous compression devices to the lower extremities. B. Notify the surgeon of the status of the client's urinary drainage. C. Obtain the client's temperature using a rectal thermometer. D. Increase the flow rate of the continuous bladder irrigation.
Answer: D Rationale: A. Discontinuing the continuous compression devices to the lower extremities is unsafe and may result in the client experiencing deep vein thrombosis and pulmonary embolus. Maintaining these devices is a dependent function of the nurse. B. Notifying the surgeon is unnecessary at this time. If the status of the client's urinary drainage intensifies, then the surgeon should be notified. C. Obtaining a rectal temperature from a client who has had a prostatectomy is contraindicated. The rectal probe could traumatize the surgical area. D. The surgeon's prescriptions indicate that the continuous bladder irrigation should be maintained at a flow rate that keeps the urinary drainage pink; this also implies the absence of clots.
A nurse must obtain a urine specimen from a client. Which nursing intervention is the greatest help to most people who need to void for a urine test? A. Exerting manual pressure on the abdomen B. Encouraging a backward rocking motion C. Running water in the sink D. Providing for privacy
Answer: D Rationale: A. Manual bladder compression (Crede maneuver) is performed when a client has bladder flaccidity. B. This rocking motion is used to promote a bowel movement, not voiding. C. Although running water in the sink may be helpful, it is not as effective as an intervention in another option. D. Tending to bodily functions is a personal, private activity in the North American culture. Providing privacy supports client dignity and generally promotes voiding.
Which is an effective nursing intervention to prevent urinary tract infections? A. Teach female clients to wipe from the back to the front after urinating. B. Advise clients to report burning on urination to health-care providers. C. Instruct clients to use bath powder to absorb perineal perspiration. D. Encourage clients to drink several quarts of fluid daily.
Answer: D Rationale: A. The opposite should be done to prevent microorganisms from the intestines (e.g., Escherichia coli) from being drawn from the anus toward the urinary meatus. Wiping from front to back follows the principles of clean to dirty. B. Reporting burning on urination to a health-care provider will not prevent a urinary tract infection. Burning on urination (dysuria) is a response to acidic urine flowing over inflamed mucous membranes and is a sign of a urinary tract infection. C. Bath powder should be avoided because it has been implicated as a precipitating cause of gynecological cancer and is a respiratory irritant. D. Drinking a minimum of 2,000 mL of fluid a day produces adequately dilute urine, washes out solutes, and flushes microorganisms from the distal urethra and urinary meatus.
When a nurse assesses a client, which clinical manifestations support the presence of urinary retention? Select all that apply. A. Nocturia B. Hematuria C. Bladder contractions D. Suprapubic distention E. Frequent small voidings
Answer: D, E Rationale: A. Excessive urination at night is called nocturia. A person with urinary retention will have small, frequent voidings or dribbling (overflow incontinence) rather than a complete discharge of urine from the bladder. B. Hematuria is the presence of red blood cells in the urine. It is associated with bladder inflammation, infection, or trauma, not urinary retention. C. Urinary retention may produce an atonic bladder rather than bladder contractions. D. The bladder lies in the pelvic cavity behind the symphysis pubis. When it fills with urine (600 mL), the bladder extends above the symphysis pubis, and when greatly distended (2,000 to 3,000 mL), it can reach to the umbilicus. E. With urinary retention, the bladder fills with urine, causing distention. Eventually, the external urethral sphincter temporarily opens to allow a small volume of urine to pass out of the bladder (overflow incontinence, retention with overflow).
A nurse is caring for a female client on bedrest who has a urinary retention catheter. Which should the nurse do? Select all that apply. A. Position the tubing through the side rail of the bed. B. Ensure the tubing is positioned under the leg. C. Label the tubing with the date of insertion. D. Irrigate the tubing to ensure its patency. E. Secure the tubing to the client's leg.
Answer: E Rationale: A. If retention catheter tubing is left on or through a side rail, the catheter may inadvertently be pulled out when the side rail is moved. In addition, the collection bag must be kept below the level of the bladder to promote the flow of urine from the bladder by gravity and prevent a flow of urine back into the bladder from the catheter. B. Positioning the tubing under the leg may put pressure on the drainage tubing that can interrupt the flow of urine from the bladder. The tubing should be maintained over, not under, the leg. C. Labeling the tubing with the date of insertion should be documented on the client's clinical record, not on the tubing. D. Irrigating the tubing is contraindicated because it may introduce microorganisms into the bladder that can cause an infection. Irrigation of a urinary retention catheter requires a prescription and is a dependent function of the nurse. E. Securing the tubing to the client's leg prevents tension on the urinary meatus.
