(Quiz 10) Fundamentals of Success- Urinary Elimination

A

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

B

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

A

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

D

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.

A, C

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.

B, D

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

B

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

A

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

C

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

D

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

D

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.

D

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

B

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

A

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.

C

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

D

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

A, B, C, D, E

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

C

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.

E

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.

A

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

B

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

C

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.

C

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

B

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

D

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.

3, 4, 1, 5, 6, 2

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.

D

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

B

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

D

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.

6, 4, 2, 3, 5, 1

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.

A

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.

C

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.

A

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?"

D, E

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

C, D, E

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

C

Which assessment is not related to monitoring both urine and stool? A. Constituents B. Urgency C. Shape D. Color