PrepU Chapter 37 Urinary elimination

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? "Don't worry, this is a normal condition for older adults." "It would be best just to get some adult diapers." "Let's explore structuring activities and toileting breaks." "Let me refer you to a urologist who can help you."

"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.

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult? Acute confusion Nausea Dysuria High fever

Acute confusion Symptoms of UTI are different in the older adult, especially if the immune system is depressed. Rather than experiencing painful urination and a high fever, the older adult will become acutely confused.

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

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

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

Keep muscles contracted for at least 10 seconds. Explanation: Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

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

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Start the procedure over and attempt to place the new catheter directly above misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Never remove a catheter from the vagina and insert it in the urethra as this action can cause cross-contamination.

The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter? "Let me talk to your health care provider about a condom catheter." "This is the only option for catheterization." "This is what your health care provider has prescribed." "Indwelling catheters do not hurt, and I will be careful placing it."

Let me talk to your health care provider about a condom catheter." The nurse will support the client's autonomy by investigating other options, such as a condom catheter. It is nontherapeutic to discount the client's concern or to tell the client that this is the only catheterization option.

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

Monitoring the characteristics of the urinary output The effectiveness of therapy is determined by the urine characteristics. On completion of the therapy with continuous bladder irrigation, the client should exhibit urine that is clear, without evidence of clots or debris. The client will have no PVR during therapy. Palpation of the bladder region and calculation of a particular outflow rate do not determine the success or failure of therapy.

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

Prime the tubing with the solution. When providing continuous irrigation, the nurse must prime the tubing with the irrigation solution to ensure that no air enters the system. The nurse should hang the sterile irrigating solution from an IV pole, rather than place it on the bed, to allow it to flow freely. The nurse empties the balloon with a syringe and also cleans the urinary meatus when removing the catheter—not when irrigating the catheter.

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

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

The client has an enlarged prostate. Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.

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

Wearing gloves when handling the urine??

A urinary ____ involves the surgical creation of an alternative route for excretion of urine.

diversion

The specific_____ of urine is a measure of the density of urine compared with the density of water.

gravity

The____ is the basic structural and functional unit of the kidneys.

neuphron

A cutaneous ureterostomy is a type of incontinent cutaneous urinary diversion in which the ureters are directed through the abdominal wall and attached to an opening in the skin.

t

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

traight catheter Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. A suprapubic catheter is used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area.

The nurse is caring for a client diagnosed with a urinary tract infection. The primary care provider orders include an antibiotic, an antipyretic, and a urine culture and sensitivity, and urine specimen for nitrates. Which actions should the nurse take? Select all that apply. Obtain the urine specimens before beginning the ordered antibiotic. Place the collected specimen with proper label in a biohazard bag and send it to the lab after collection. Administer the antipyretic before obtaining the urine culture and sensitivity. Collect the first void clean urine specimen since the client presented in the emergency department at 0500. Instruct the client on the midstream urine collection process.

-Collect the first void clean urine specimen since the client presented in the emergency department at 0500. -Obtain the urine specimens before beginning the ordered antibiotic. -Instruct the client on the midstream urine collection process. -Place the collected specimen with proper label in a biohazard bag and send it to the lab after collection. Whenever possible, the best specimen is the first void urine specimen because it will be the most concentrated with any bacteria or nitrates. The nurse, if possible, should collect the urine culture and sensitivity before providing the first dose of the antibiotic so the culture truly reflects the microbes. Antipyretics are also administered after obtaining cultures. The nurse should instruct the client on the correct process to obtain the urine culture. The nurse should place the specimen in a biohazard bag and send it to the lab after collection.

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

24-hour specimen A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.

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

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

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

Auscultate over the site with a stethoscope to listen for a bruit. 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? Incontinence after the age of 3 years is not normal. Daytime continence is usually not achieved by boys until age 5. Boys may walk by 1 year and should be continent by 3 years. Boys may take longer for daytime continence than girls.

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

Which symptom will have a great impact on the extracellular fluid for water conservation? Small laceration Burns Fracture Pain

Burns The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis (sweating) secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.

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, then cleanse each side of the labia with prepared aseptic swabs. Catch the urine in the cup after cleansing the perineum. Catch the urine while holding the labia apart, after cleansing. Fill the specimen cup. Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.

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

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

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

The nurse is 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? Instruct on proper wiping technique Encourage fluids Contact the health care provider Monitor vital signs

Contact the health care provider 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. tieu ra mu

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. Discontinue to catheter and report this to the healthcare provider. Ensure that the drainage bag is above the level of the bladder at all times. Perform, or allow client to perform, perineal hygiene at least once daily. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP).

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

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. Perform, or allow client to perform, perineal hygiene at least once daily. Discontinue to catheter and report this to the healthcare provider. Ensure that the drainage bag is above the level of the bladder at all times. Contact the health care provider to ask for an order for catheter discontinuation. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP).

Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily. 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 nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women? Contract abdominal muscles 10 times per day. Contract the pubic muscles for 3 seconds, then relax. Lie on the floor, raise, then lower your legs 20 times per day. Squat down and then jump up to a standing position.

Contract the pubic muscles for 3 seconds, then relax. Pelvic floor exercises, or Kegel exercises, strengthen the pubococcygeal muscles and effectively promote urinary control. The nurse should inform the women to locate the muscles used to start and stop urinating. Then contract those muscles and relax them repeatedly. Strengthening the abdominal muscles will not help with urinary control. Squatting, jumping, and performing leg lifts will help to strengthen the quadriceps and hamstrings.

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply. Difficulty voiding Urinary incontinence Urinary retention Burning or irritation while voiding Urinary frequency Increased volume of urine output

Difficulty voiding Urinary incontinence Urinary retention Burning or irritation while voiding The client may experience burning or irritation the first few times he or she voids after removal, due to urethral irritation. If the catheter was in place for more than a few days, decreased bladder muscle tone and swelling of the urethra may cause the client to experience difficulty voiding or an inability to void. Accidents are possible until the client establishes voluntary control of the bladder. The nurse should monitor the client for urinary retention. Urinary frequency and increased volume of urine output are not complications of urinary function following removal of an indwelling catheter.

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

Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Avoid clothing that is tight and restrictive on the lower half of the body. Wear underwear with a cotton crotch. 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 performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next? Wipe off some of the ultrasound gel and rescan. Ensure proper positioning of the scanner head and rescan. Place the client on either side and rescan. Have the client drink 8 ounces of water every 15 minutes for 1 hour.

Ensure proper positioning of the scanner head and rescan. The scanner head should be repositioned, and the bladder should be rescanned before assuming that the bladder is truly empty. Additional ultrasound gel may need to be added for the scanner to work properly. If the bladder is truly distended, the client may become more uncomfortable from drinking additional water. The best position for bladder scanning is supine.

Nocturnal _____, known as nighttime bedwetting, usually subsides by 6 years of age.

Enuresis

A nurse documents that a patient has anuria when the 24-hour urine output is less than 400 mL.

F

The urinary bladder muscle is innervated by the sympathetic nervous system, which carries motor impulses to the bladder and inhibitory impulses to the internal sphincter.

F

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

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

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

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. Explanation: The external condom catheter is not in the bladder. It collects urine into a drainage bag without theuti risk of infection associated with indwelling urinary catheters which are placed in the bladder. Because it is not sterile, a sterile urine specimen cannot be obtained. Often, the client does not place the external condom catheter by himself. The catheter is changed every day and the skin of the penis is assessed.

A nurse is caring for a female client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action? Many clients find it embarrassing or degrading to use a bedpan. The bed should be lowered to the lowest height before placing the bedpan. Incorrect placement of a bedpan has been linked to development of UTIs. Bedpans should not be used if the client needs to defecate.

Many clients find it embarrassing or degrading to use a bedpan. Many clients find it difficult and embarrassing to use the bedpan. The nurse should be aware of this fact and approach the client with dignity and professionalism. Bedpan use is not associated with UTIs and bedpans may be used for defecation. The bed should be raised to a comfortable working height for the caregiver to prevent back injury. After removing the bedpan, the nurse would then lower the bed to its lowest position.

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

Nephron 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.

The nurse is reviewing a urinalysis laboratory report of a client. The nurse notes there are nitrates and white blood cells present in the urine. Based on these results, what intervention(s) would be necessary? Select all that apply. Notify the health care provider. Prepare to obtain a urine culture. Prepare to obtain a midstream specimen. Obtain another voided specimen for comparison. Prepare to obtain a specimen by catheterization.

Notify the health care provider. Prepare to obtain a urine culture. Prepare to obtain a specimen by catheterization. If the urinalysis results show nitrates and white blood cells, it indicates that there could be an infection present. These results would warrant further testing. The health care provider should be notified. The nurse would anticipate receiving a prescription to obtain a sterile urine specimen by catheterization and the specimen should be sent to the laboratory to be cultured. Once the organisms are identified on the culture, the correct type of antibiotic can be prescribed by the health care provider. Neither obtaining another voided specimen nor collecting a midstream urine would provide a sterile specimen.

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

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

The nurse is caring for an older adult client who has had a condom catheter applied. Which intervention will the nurse include in the care of this client? Perform thorough skin care daily. Make sure the condom sheath is secured tightly to the penis. Change the condom catheter every other day. Ensure the tubing is flush to the tip of the penis.

Perform thorough skin care daily. Clients with condom catheters (also known as urinary sheaths), require thorough skin care daily to prevent skin breakdown. The condom sheath should be changed daily, not every other day. The condom sheath should be secured in place, but should not be tight on the penis for risk of reduced blood flow/damage. Drainage tubing should be 1 to 2 in (2.5 to 5 cm) from the tip of the penis to prevent urine irritating the glans.

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. 1Provide instruction to the client. 2Submit collected specimen to the health care professional. 3Clean the area surrounding the urinary meatus with the provided cloth. 4Void a small amount into toilet or bedpan. 5Secure the lid on the specimen container. 6Void into the provided collection device.

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

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. 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.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? Absence of discharge Moist perineal skin Reddened perineal skin Presence of smegma

Reddened perineal skin The presence of reddened perineal skin is an abnormal finding. The healthy skin should be moist and noninflamed with no discharge present. Smegma (an accumulation of white, odorous secretions from sebaceous glands found under the labia minora in women and under the foreskin in men) is considered a normal finding.

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 Encouraging the client to stay close to home Fluid restriction Indwelling catheterizatio

Regular toileting routine 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.

A nurse is caring for an older adult client who has been prescribed a condom catheter. What potential problems related to the use of a condom catheter should the nurse monitor in the client? Select all that apply. Excoriation of the skin in the glans area Inability to control urinary elimination Restricted blood flow to the glans tissue Frequent urinary tract infection Kinks in tubing that encourage backflow of urine

Restricted blood flow to the glans tissue Excoriation of the skin in the glans area Kinks in tubing that encourage backflow of urine A potential problem that can occur with the use of condom catheters is the restriction of blood flow to the skin and tissues of the penis if the sheath is applied too tightly. Another potential problem is the tendency of moisture to accumulate beneath the sheath leading to skin breakdown or excoriation, especially the skin around the glans. A retention catheter, not a condom catheter, could lead to urinary tract infection. Use of a condom catheter does not lead to the inability to control urinary elimination. Care must be taken to fasten the condom securely enough to prevent leakage. Monitor for kinks in the tubing since this may encourage backflow of urine. Ref

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 eight 8-oz glasses of cranberry juice daily. The client drinks two glasses of water before and after sexual intercourse. The client soaks in the bathtub daily for perineal care. Since the client is symptom-free, she no longer takes the prescribed antibiotics.

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

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

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

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

The client should avoid wearing tight clothes or belts near the site. Clients should avoid baths and public pools as well as wearing tight clothes and belts around the exit site. Once the site is healed, some health care providers do not require clients to wear a dressing unless the site is leaking. Clean technique is sometimes allowed in the home.

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

The novice nurse selects an 18 French Foley catheter to insert. A 14F to 16F catheter should be used when catheterizing an adult client. Size 18F can distend the urethra and cause more discomfort to the client during the procedure, as well as increase erosion of the bladder. If resistance is met, having the client take a deep breath helps relaxes the external sphincter. Placing a trash receptacle within easy reach trash allows for prompt disposal of used supplies and reduces the risk of contaminating the sterile field. The dorsal recumbent position allows adequate visualization of the urinary meatus.

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

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

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

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

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

Urinal A urinal is the best choice to collect urine from a nonambulatory male client. A specimen hat is for a commode. A bedpan is not the best choice for a male client. A large urine collection bag would be used with an indwelling catheter.

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

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.

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

Wearing gloves when handling the urine All of these interventions would be important to ensure safety in handling the client's urine and obtaining an accurate output. However, safety with handling body fluids would be a priority for the nurse to decrease risk of exposure to pathogens or blood that may be in the client's urine.

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

Wearing gloves when handling the urine All of these interventions would be important to ensure safety in handling the client's urine and obtaining an accurate output. However, safety with handling body fluids would be a priority for the nurse to decrease risk of exposure to pathogens or blood that may be in the client's urine.

Which is true regarding the normal urination? Catheterized clients should drain a minimum of 30 mL of urine per hour. In adults, the average amount of urine per void is 500 mL. Urinary output does not vary all that much between adults and children. In adults, the amount of urine voided typically does not depend on fluid intake and losses.

atheterized clients should drain a minimum of 30 mL of urine per hour. Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.

A woman is reporting bladder urgency. It is most important to assess: vitamin supplements. weight. caffeine intake. exercise.

caffeine intake. Alcohol and caffeine-containing fluids or food, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.

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

check electronic health record for medical order. The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after it has been confirmed that an order for irrigation exists.

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 explaining to the client that the procedure will be painful maintaining the client without liquids before the procedure inserting a Foley catheter the morning of the procedure

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? strongly aromatic, amber clear, dark amber light yellow, clear cloudy, foul odor

cloudy, foul odor 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 has been NPO. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color? dark amber colorless pale yellow tea colored

dark amber

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

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

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

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 total stress urge

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.

the health care provider prescribes a long-term continuous drainage system to monitor a chronically ill client. What type of catheter would best suit this client's needs? ndwelling urethral catheter intermittent urethral catheter external catheter suprapubic catheter

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The nurse is planning care for a client with a newly placed urostomy. For what priority problems will the nurse address and provide interventions? Select all that apply. impaired urinary elimination urinary retention reflex urinary incontinence situational low self-esteem risk for infection

impaired urinary elimination situational low self-esteem risk for infection The client with a new urostomy may be at risk for: - impaired skin integrity and - infection if the client does not care properly for the ostomy. - The client may experience a change in self-esteem due to this different way of eliminating. The client will not experience reflex incontinence, because the urostomy will continually drain urine. As long as the urostomy functions appropriately, the client should not experience impaired urinary elimination.

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 indwelling urethral catheter Foley catheter retention catheter

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

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a: overactive bladder. cystocele. enuresis. neurogenic bladder.

neurogenic bladder. 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.

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? Overflow Functional Stress Urge

stress Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing

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

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

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

strongly aromatic, dark amber The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.

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

strongly aromatic, dark amber The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.

The nurse is caring for a client with a Foley catheter in place who has a prescription for a sterile urine specimen for culture and sensitivity. The nurse implements which techniques to obtain the prescribed urine specimen? Select all that apply. The nurse disconnects the catheter and allows the urine to drip into the specimen container. The nurse allows the urine to flow from the collection bag into the specimen container. The nurse clamps the tube below the access port for 40 minutes to allow urine to accumulate. The nurse dons clean gloves and cleanses the port with aseptic solution. The nurse uses a syringe to withdraw urine from the port.

the nurse uses a syringe to withdraw urine from the port. The nurse dons clean gloves and cleanses the port with aseptic solution. When collecting a sterile urine specimen from a Foley catheter, the nurse wears clean gloves, cleans the port with an aseptic solution, and withdraws the specimen from the port with a syringe. The specimen should not be taken from the collecting bag because it may not be fresh and could result in an inaccurate analysis. The catheter should not be disconnected in order to prevent bacteria from entering the urinary system. If urine is not present in the tube, the tube may be clamped, but not to exceed 30 minutes.

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: use three wipes provided; one to clean each side of the urinary meatus, and one in the middle from front to back." urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." keep the labia spread after cleaning and during collection of the specimen." wash my hands before collecting the clean catch urine specimen."

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