Urinary Elimination- PassPoint Questions

A physician orders hourly urine output measurement for a postoperative client with an indwelling catheter. The nurse records these amounts of output for 2 consecutive hours: 8 a.m. (0800): 50 ml; 9 a.m. (0900): 60 ml. Based on these amounts, which action should the nurse take?

A: Continue to monitor and record hourly urine output. Rationale: Normal urine output for an adult with an indwelling catheter is at least 30 ml/hour. Therefore, this client's output is normal. Beyond continued evaluation, no nursing action is warranted.

A client with fever and urinary urgency must provide a urine specimen for culture and sensitivity. The nurse should instruct the client to collect the specimen from the

A: middle stream of urine from the bladder. Rationale: The midstream specimen is recommended because it's less likely to be contaminated with microorganisms from the external genitalia than other specimens. It isn't necessary to collect a full volume of urine for a urine culture and sensitivity.

Which question should the nurse ask first when obtaining a history from the parent of a school-age child with a fever, malaise, and swelling around the eyes?

A: "Does the child urinate as much as usual?" Rationale: Most likely, the nurse suspects that the child is exhibiting signs and symptoms of glomerulonephritis, such as periorbital edema and fever. Other signs and symptoms include loss of appetite, dark-colored urine, pallor, headaches, and abdominal pain. To confirm this suspicion, the nurse would ask about the child's urinary elimination patterns.

A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1,000-mL intake. What should the nurse do first?

A: Assess for bladder distention. Rationale: The imbalance between the client's intake and output indicates that the client may be retaining urine since the removal of his Foley catheter. The nurse's first action is to validate this assumption by assessing for bladder distention. Applying a condom catheter will not relieve urinary retention; condom catheters are meant to be used for incontinence. A urine specimen for a culture is obtained if a urinary infection is suspected, but this is not a priority at this point. Kegel exercises are helpful in controlling urinary dribbling but do not treat retention.

A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. What should the nurse do?

A: Check on the client at regular intervals to ascertain the need to use the bathroom. Rationale: Confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The nurse or UAP should check on the client regularly to determine needs regarding elimination. Restraints, including bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written prescription from a health care provider (HCP) before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety.

A client is diagnosed with acute pyelonephritis. What should the nurse instruct the client to do?

A: Empty the bladder every 2 to 3 hours. Rationale: Pyelonephritis usually begins with colonization and infection of the lower urinary tract via the ascending urethral route, and the client should have an adequate intake of fluids to promote the flushing action of urination. Bubble baths and limiting fluid intake increase the risk of developing a urinary tract infection. Antibiotics should be used on a short-term basis because the risk of antibiotic resistance may lead to breakthrough infections with increasingly virulent pathogens.

Which intervention should the nurse suggest to help a client with multiple sclerosis avoid episodes of urinary incontinence?

A: Establish a regular voiding schedule. Rationale: Maintaining a regular voiding pattern is the most appropriate measure to help the client avoid urinary incontinence. Fluid intake is not related to incontinence. Incontinence is related to the strength of the detrusor and urethral sphincter muscles. Inserting an indwelling catheter would be a treatment of last resort because of the increased risk of infection. If catheterization is required, intermittent self-catheterization is preferred because of its lower risk of infection. Antibiotics do not influence urinary incontinence.

When assessing an 18-year-old primipara who gave birth under epidural anesthesia 24 hours ago, the nurse determines that the fundus is firm but to the right of midline. Based on this finding, the nurse should further assess for which complication?

A: Urinary retention Rationale: A full bladder is likely to push the uterus to the right of midline, so the nurse should further assess for symptoms of urinary retention. A full bladder can prevent the uterus from contracting properly (uterine atony), possibly leading to hemorrhage. When the bladder is empty, it normally is nonpalpable and lies about in the midline.

A nurse is caring for an elderly adult client admitted to the hospital from a nursing home because of a change in behavior. The client has a diagnosis of Alzheimer's disease and has started to experience episodes of incontinence. The hospital staff is having difficulty with toileting because the client wanders around the unit all day. To assist with elimination, a nurse should:

A: incorporate the client's toileting schedule into the pattern of his wandering. Rationale: Incorporating the client's toileting schedule into his wandering assists with elimination and increases the chance of continent episodes. Sedation and restraints will decrease the client's mobility but won't decrease the number of incontinent episodes. Wearing two briefs at a time won't ensure urine absorption and won't address the incontinence issue.

After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which goal?

A: keeps the new urethra from closing Rationale: The main purpose of the urethral catheter is to maintain patency of the reconstructed urethra. The catheter prevents the new tissue inside the urethra from healing on itself. However, the urethral catheter can cause bladder spasms. Recently, stents have been used instead of catheters. The urethral catheter will have no effect on the child's pain level. In fact, because bladder spasms are associated with its use, the child's problems of pain may actually increase. Urine output can be measured through the suprapubic catheter because it provides an alternative route for urinary elimination, thus keeping the bladder empty and pressure-free.

Which aspects of client care would be most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?

A: obtaining a urine specimen for a culture and sensitivity analysis from a client who has an indwelling urinary catheter inserted Rationale: The most appropriate action to delegate to a UAP is collection of a urine specimen for a culture and sensitivity analysis. Collecting the specimen does not require sterile technique.