NUR 310 - Urinary Elimination

A clients results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 1015, glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the results? 1. Dehydration 2. Diabetic ketoacidosis 3. Trauma 4. Urinary tract infection

Urinary tract infection Rationale: The pH, glucose, specific gravity, and protein are all within normal limits. Urine is usually clear to slightly cloudy, and WBC count can be from 0 to 4. Therefore, the gross cloudiness and WBC count of 1015 are not normal, indicating a urinary tract infection.

The nurse is instructing a client on ways to manage stress urinary incontinence. What should be included in this clients teaching? Standard Text: Select all that apply. 1. Limit intake of caffeine. 2. Limit intake of alcohol. 3. Increase intake of citrus juices. 4. Limit evening fluid intake. 5. Increase intake of beverages with artificial sweeteners.

1, 2, 4 Rationale 1: Clients with stress incontinence should be instructed to limit the intake of caffeine. Rationale 2: Clients with stress incontinence should be instructed to limit the intake of alcohol. Rationale 3: Clients with stress incontinence should be instructed to limit, not increase, the intake of citrus juices. Rationale 4: Clients with stress incontinence should be instructed to limit evening fluid intake. Rationale 5: Clients with stress incontinence should be instructed to limit, not increase, the intake of beverages with artificial sweeteners.

A client is complaining of pain with urination. The nurse realizes that the client needs to be assessed for which health problems? Standard Text: Select all that apply. 1. Urethral stricture 2. Renal failure 3. Urethral injury 4. Bladder injury 5. Urinary infection

1, 3, 4, 5 Rationale 1: Dysuria means voiding that is either painful or difficult. It can occur with a urethral stricture. Rationale 2: Dysuria means voiding that is either painful or difficult. It is not typically associated with renal failure. Rationale 3: Dysuria means voiding that is either painful or difficult. It can occur with a urethral injury. Rationale 4: Dysuria means voiding that is either painful or difficult. It can occur with a bladder injury. Rationale 5: Dysuria means voiding that is either painful or difficult. It can occur with a urinary infection.

An older female client with a history of urinary tract infections has an indwelling urinary catheter. What should the nurse do to reduce this clients risk of developing an infection because of the catheter? Standard Text: Select all that apply. 1. Maintain a sterile closed drainage system. 2. Clean the peri-urethral area with antiseptics. 3. Ensure the catheter and tubing are not kinked. 4. Wash his or her hands before manipulating the catheter. 5. Keep the collection bag below the level of the bladder.

1, 3, 4, 5 Rationale 1: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain a sterile closed drainage system. Rationale 2: Cleaning the peri-urethral area with antiseptics is an action that should be avoided. Rationale 3: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should maintain unobstructed urine flow by making sure the catheter and tubing are not kinked. Rationale 4: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should wash his or her hands before any manipulation of the catheter or collection system. Rationale 5: To prevent a urinary tract infection in the presence of an indwelling urinary catheter, the nurse should keep the collection bag below the level of the bladder at all times.

The nurse is documenting the insertion of a retention catheter for a client. What should be included in this documentation? Standard Text: Select all that apply. 1. Catheter size 2. Location of the drainage bag 3. Amount of urine that drained after insertion 4. Name of the physician who prescribed the insertion of the catheter 5. Client tolerance of the procedure

1, 3, 5 Rationale 1: The nurse should document the catheterization procedure, including the catheter size. Rationale 2: The nurse does not need to document the location of the drainage bag. Rationale 3: The nurse should document the amount of urine that drained after insertion. Rationale 4: The nurse does not need to document the name of the physician who prescribed the insertion of the catheter. Rationale 5: The nurse should document the clients tolerance of the procedure.

A clients urine pH is 8.0. What further assessments would be indicated for this client? Standard Text: Select all that apply. 1. Intake of fruits and vegetables 2. Intake of cranberries 3. Intake of high-protein foods 4. Symptoms of diarrhea 5. Symptoms of a urinary tract infection

1, 5 Rationale 1: Alkaline urine might indicate a diet high in fruits and vegetables. Rationale 2: Acidic urine is found in an intake high in cranberries. Rationale 3: Acidic urine is found in a diet high in proteins. Rationale 4: Acidic urine is found with diarrhea. Rationale 5: Alkaline urine might indicate a urinary tract infection.

A client needs a test to determine the amount of residual urine. The nurse realizes that this assessment is used for which reason(s)? Standard Text: Select all that apply. 1. To evaluate the glomerular filtration rate 2. To determine the extent of renal failure 3. To determine the amount of retained urine after voiding 4. To determine the need for medications 5. To evaluate fluid volume status

3, 4 Rationale 1: Residual urine is not measured to evaluate the glomerular filtration rate. Rationale 2: Residual urine is not measured to determine the extent of renal failure. Rationale 3: Residual urine is measured to assess the amount of retained urine after voiding. Rationale 4: Residual urine is measured to determine the need for interventions such as medications. Rationale 5: Residual urine is not measured to evaluate fluid volume status.

A UAP has applied a condom catheter to a client. The nurse should document what information about this procedure? Standard Text: Select all that apply. 1. Number of ml of fluid used to inflate the balloon 2. Location of the drainage bag 3. Name of the UAP who applied the device 4. Time and date that the condom catheter was applied 5. Integrity of the penis

4, 5 Rationale 1: A condom catheter does not have a balloon that needs to be inflated. Rationale 2: The nurse does not need to document the location of the drainage bag. Rationale 3: The nurse does not need to document the name of the UAP who applied the device. Rationale 4: The nurse should document the application of the condom, including the time. Rationale 5: The nurse should document any pertinent observations, such as the integrity of the penis.

A client with an indwelling urinary catheter is prescribed to receive sterile normal saline bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the clients output as being 1425 mL. What is the clients urine output for the 8-hour shift?

625 mL Rationale: The client is to receive 800 mL of bladder irrigant for the 8-hour shift. The nurse needs to subtract the bladder irrigant total from the total output, or 1425 800 = 625 mL. This is the clients urine output for the 8-hour shift.

The nurse has completed closed irrigation of a clients retention catheter. What specific information should the nurse document about this procedure? 1. Number of ml of solution used to inflate the balloon of the catheter 2. Abnormal drainage, such as blood clots, pus, or mucous shreds 3. Location of the draining bag 4. Technique used to conduct the irrigation

Abnormal drainage, such as blood clots, pus, or mucous shreds Rationale: The nurse should note any abnormal constituents, such as blood clots, pus, or mucous shreds.

The nurse is assessing a clients urinary elimination. Which factor should the nurse keep in mind as influencing this elimination? 1. Age 2. Body image 3. Knowledge 4. Socioeconomic status

Age Rationale: Development factors such as how old the client is influence urinary elimination.

The nurse realizes that which client is at risk for difficulty in urinary elimination? 1. A client who had bladder cancer and now has a newly created ileal conduit 2. A 25-year-old female client with low self-esteem 3. An 80-year-old male reporting frequent urination at night 4. The client with hypertension who takes a diuretic every day for blood pressure

An 80-year-old male reporting frequent urination at night Rationale: The client who is 80 years old with frequent urination at night is having problems with his prostate. Older male adults experience urinary retention due to prostate enlargement causing an alteration in urinary elimination.

The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for this client? 1. Incontinent urinary diversion 2. The kock pouch. 3. Neobladder 4. Nephrostomy

Incontinent urinary diversion Rationale: This is an incontinent urinary diversion (ileal conduit).

The nurse wants to delegate the application of a condom catheter to unlicensed assistive personnel (UAP). What must the nurse assess prior to delegating this task? 1. Assess whether the client has unique needs. 2. Measure the clients intake. 3. Assist the client out of bed to a chair. 4. Assess changes in the clients mobility status.

Assess whether the client has unique needs Rationale: Applying a condom catheter may be delegated to UAP. However, the nurse must determine whether the specific client has unique needs, such as impaired circulation or latex allergy, that would require special training of the UAP in the use of the condom catheter.

A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary diversion stoma. What evidence presented by the client leads to this conclusion? 1. Black with sloughing 2. Moist stoma 3. Pink and shiny 4. Slight bleeding from stoma

Black with sloughing Rationale: Black color to the stoma and sloughing are signs of necrosis of the stoma

The nurse is concerned that an older client with a retention catheter is developing a urinary tract infection. What assessment finding caused this concern? 1. Elevated blood pressure 2. Elevated heart rate 3. Confusion 4. Leg pain

Confusion Rationale: In the older client, confusion can be an early sign of urinary tract infection.

The nurse is performing urinary catheterization for a client. After using the nondominant hand to separate the clients labia for cleansing, the nurse will maintain this hand as being 1. Sterile. 2. Contaminated. 3. Able to evaluate the effectiveness of the catheter balloon. 4. Clean.

Contaminated Rationale: When performing urinary catheterization, the nondominant hand is considered contaminated once it touches the clients skin.

A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the client is experiencing nocturia due to which factor? 1. Decrease in bladder tone 2. Decrease in blood supply 3. Decrease in number of nephrons 4. Decrease in cardiac output

Decrease in bladder tone Rationale: Nocturia is voiding frequently at night. An increased intake of fluid causes some increase in the frequency of voiding. Conditions such as urinary tract infection (UTI), stress, and pregnancy can cause frequent voiding of small quantities of urine. Total fluid intake and output may be normal.

A client is diagnosed with an elevated aldosterone level. The nurse realizes that this finding will affect what aspect of urinary elimination? 1. Increased urine output 2. Urinary incontinence 3. Decreased urine output 4. Urinary retention

Decreased urine output Rationale: When aldosterone is released from the adrenal cortex, sodium and water are reabsorbed in greater quantities, increasing the blood volume and decreasing urinary output.

A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary elimination? 1. Dont interrupt your day by going to the bathroom; wait until youre at a good stopping place. 2. Drink 8 to 10 glasses of water daily. 3. Urine color changes are not important. 4. Wash with soap and water every other day.

Drink 8 to 10 glasses of water daily Rationale: Drinking 8 to 10 glasses of water daily will encourage the need for bladder emptying, keeping the system flushed.

A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury will affect which aspect of urinary elimination in the client? 1. Elimination of urine from the bladder 2. Ability of the kidneys to absorb solutes 3. Ureteral function 4. Urethra function

Elimination of urine from the bladder Rationale: The bladder contains the detrusor muscle, which is responsible for expulsion of urine from the bladder. If the client has a cervical spine injury, muscle function will be affected below the level of the injury, resulting in an impaired ability to eliminate urine from the bladder.

The nurse is applying an external urinary device to a client. Before attaching the device to the drainage bag, what should the nurse do? 1. Wash his or her hands. 2. Document the clients tolerance of the procedure. 3. Instruct the client about the drainage system. 4. Ensure that the condom is not twisted.

Ensure that the condom is not twisted Rationale: The nurse should make sure that the tip of the penis is not touching the condom and that the condom is not twisted, because a twisted condom could obstruct the flow of urine.

The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion? 1. Change the appliance several times a day. 2. Increase fluid intake. 3. Notify the physician if the stoma is deep pink and shiny. 4. Strands of blood may appear in the urine.

Increase fluid intake Rationale: Increasing the fluid intake helps to flush out sediment and mucus and prevents clogging of the stoma.

The nurse is determining tasks to delegate to unlicensed assistive personnel (UAP). Which task should the nurse question before delegating to this level of health care provider? 1. Measuring intake and output 2. Assessing vital signs for clients who are clinically stable 3. Performing complete morning care for a client recovering from a stroke 4. Inserting a urinary catheter into a client

Inserting urinary catheter into a client Rationale: Due to the need for sterile technique and detailed knowledge of anatomy, insertion of a urinary catheter is not delegated to UAP.

Which intervention would the nurse plan to help a client prevent a urinary tract infection? 1. Encourage the use of bubble baths. 2. Have the client increase sugar in the diet. 3. Instruct the client to empty the bladder completely. 4. Wipe from back to front.

Instruct the client to empty the bladder completely Rationale: Completely emptying the bladder prevents stasis of urine, which would contribute to a urinary tract infection

A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter expresses the need to urinate. Which action should the nurse take to help this client? 1. Deflate and then reinflate the balloon. 2. Irrigate the catheter. 3. Reposition the catheter. 4. Retape the catheter to the abdomen.

Irrigate the catheter Rationale: Blood clots give the client the sensation to urinate when they obstruct the urine outflow; therefore, irrigation will have to remedy the problem.

A client has been admitted with incontinence. What should the nurse expect to assess in this client? 1. Client is wearing cotton undergarments. 2. Leakage of urine occurs when client laughs. 3. Leakage of urine occurs when talking with the client. 4. The skin of the client is clear without discoloration.

Leakage of urine occurs when client laughs Rationale: Incontinence involves a small leakage of urine when a client laughs.

The nurse is reviewing kidney function with a client experiencing renal failure. Identify the area in the nephron where solutes such as glucose are reabsorbed.

Loop of Henle

A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication? 1. The medication should be discontinued abruptly. 2. Notify the physician if you experience urinary retention. 3. Take a laxative every day. 4. Take the medication on an empty stomach.

Notify the physician if you experience urinary retention Rationale: A beta-adrenergic blocker such as propranolol can cause urinary retention; therefore, it would be of the utmost importance to notify the physician.

The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques should the nurse use in assessing this clients urinary system? 1. Auscultation and inspection 2. Inspection and percussion 3. Observation and auscultation 4. Palpation and observation

Palpation and observation Rationale: The hands and sense of touch are used with palpation to gather data along with observation or inspection, which visually allows the nurse to observe all responses and nonverbal behavior. It is also the most frequently used technique and the most convenient.

Which nursing intervention is appropriate when caring for a client with a retention catheter? 1. Don sterile gloves. 2. Gently retract the labia majora away from the urinary meatus. 3. Observe urine in the drainage bag. 4. Retape the catheter to the thigh.

Retape the catheter to the thigh Rationale: Retaping the catheter to the thigh after care is given prevents trauma and pain from tension and pulling.

Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is found lying on the floor? 1. Risk for Impaired Skin Integrity related to catheter placement 2. Risk for Infection related to improper handling 3. Self-Care Deficit related to presence of a retention catheter 4. Risk for Incontinence related to an obstruction

Risk for infection related to improper handling Rationale: The floor is the dirtiest place, so the drainage device should never be placed on the floor.

The nurse is concerned that a client is at risk for the development of urinary tract infections. What did the nurse assess to come to this conclusion? 1. The client is wearing tight clothing. 2. The client is employed as a computer operator. 3. The client drinks 810 8-ounce glasses of water and low-calorie beverages each day. 4. The client exercises for 3060 minutes most days of the week.

The client is wearing tight clothing Rationale: Tight-fitting pants or other clothing can cause irritation to the urethra and prevent ventilation of the perineal area, leading to an infection.

A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client indicates that teaching has been effective? 1. The client empties the drainage bag once a day. 2. The client hangs the drainage bag on the towel rod. 3. The client refuses drinks one to two 8-ounce glasses of fluid each day. 4. The client takes a shower each day.

The client takes a shower each day Rationale: The client should take a shower rather than a tub bath because sitting in a tub allows bacteria to easily access the urinary tract.

Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern Alteration related to an enlarged prostate? 1. The client will avoid bladder distention. 2. The client will maintain fluid imbalance. 3. The client will remain free of skin breakdown. 4. The client will voice increased discomfort.

The client will avoid bladder distention Rationale: Avoiding bladder distention will help eliminate stasis of urine in the bladder, which contributes to urinary tract infections, a possible complication of urine flow being obstructed from an enlarged prostate.

The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which outcome would be related to sphincter incompetence? 1. The client will empty her bladder every time she voids. 2. The client will improve her incontinence within 1 month. 3. The client will perform four to five squeezes for 5 to 10 seconds. 4. The client will stop the flow of urine when voiding.

The client will perform four to five squeezes for 5 to 10 seconds Rationale: Performing four to five squeezes for 5 to 10 seconds is the goal to start with when teaching a client Kegel exercises, which are used for stress and urge incontinence.

A clients urinalysis is reported as being normal. What were the clients results? 1. Blood present and no ketones 2. Dark amber color and output less than 500 cc in 24 hours 3. pH 6 and no glucose present 4. Specific gravity 1.035 and faint aromatic odor

pH 6 and no glucose present Rationale: Normal pH is 4.5 to 8, so a pH of 6 and no glucose present are two normal characteristics of urine.