#9 - Chapter 39: Urinary Elimination
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? A) 24-hour specimen B) clean-catch specimen C) random specimen D) intermitten specimen
A) 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.
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? A) 24-hour specimen B) clean-catch specimen C) random specimen D) intermittent specimen
A) 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 urinary catheter has been placed in a client with a bladder neck obstruction that led to urinary retention. Which intervention will the nurse PRIORITIZE to minimize the client's risk for catheter-associated urinary tract infection (CAUTI)? A) advocate for removal of the catheter as soon as it becomes unnecessary B) promote intake of at least 2.5 L of fluids daily, unless contraindicated C) aspirate urine for visual inspection for pus every 12 hours D) flush the catheter with sterile water every 6 hours
A) advocate for removal of the catheter as soon as it becomes unnecessary Early removal of catheters is key to the prevention of CAUTI. Fluid intake would be ensured, but this does not reduce the risk for CAUTI to the same degree as early catheter removal. Inspection does not prevent infection, and flushing the catheter ensures patency but does not prevent UTI.
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? A) anuria B) oliguria C) nocturia D) urinary retention
A) anuria Absence of urine for a 24-hour period reflects anuria.
A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? A) asking the client when he or she had last urinated B) determining any pain when palpating the lower abdomen C) palpating the bladder above the symphysis pubis D) obtaining the bladder scanner to check the urine volume
A) asking the client when he or she had last urination In assessing the bladder, the nurse would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.
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? A) catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet B) catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs C) catch the urine while holding the labia apart, after cleansing. Fill the specimen cup D) catch the urine in the cup after cleansing the perineum
A) 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.
The nurse is teaching an older adult female who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen? A) catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet B) catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs C) catch the urine while holding the labia apart, after cleansing. Fill the specimen cup. D) catch the urine in the cup after cleansing the perineum
A) 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.
Which is true regarding the normal urination? A) catheterized clients should drain a minimum of 30 mL of urine per hour B) in adults, the average amount of urine per void is 500 mL C) urinary output does not vary all that much between adults and children D) in adults, the amount of urine voided typically does not depend on fluid intake and losses
A) catheterized 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.
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? A) checking that the client has signed a consent form for the procedure B) explaining to the client that the procedure will be painful C) maintaining the client without liquids before the procedure D) inserting a Foley catheter the morning of the procedure
A) checking that the client has signed a consent form for the procedure 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? A) cloudy, foul odor B) light yellow, clear C) clear, dark amber D) strongly aromatic, amber
A) 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.
Three days post-surgery for breast reconstruction, the nurse assess 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. A) contact the health care provider to ask for an order for catheter discontinuation B) delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP) C) perform, or allow client to perform, perineal hygiene at least once daily D) ensure that the drainage bag is above the level of the bladder at all times E) discontinue to catheter and report this to the healthcare provider
A) contact the health care provider to ask for an order for catheter discontinuation C) 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.
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? A) dehydration B) hypovolemia C) balanced fluids D) kidney injury
A) dehydration 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 kidney injury.
An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem? A) discuss the use of protective undergarments to avoid embarrassment from incontinence B) encourage the client to confide in family members and tell them about the accidents C) inform the client that this is not normal and make a referral to a urologist D) tell the client that this happens to all people when they get older
A) discuss the use of protective undergarments to avoid embarrassment from incontinence The nurse will promote the client's self-esteem by openly discussing adult undergarments. The client has no other health problems, and can benefit by learning how to self-manage this concern. Encouraging the client to tell family members does not support the client's desire to refrain from telling others about this issue. The client does not need referral to a urologist at this time. Reassuring the client that others have this concern is nontherapeutic and does not directly meet the client's concern.
What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? A) it collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters B) the client can apply it himself with minimal supervision C) it can be left in place for a long period of time D) a sterile urine specimen can be obtained from the drainage bag tubing
A) it collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters The external condom catheter is not in the bladder. It collects urine into a drainage bag without the 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.
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? A) leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter B) immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics C) ask the client to bear down until the catheter is expelled D) remove the catheter from the vagina and attempt to insert it into the bladder
A) leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.
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? A) many clients find it embarrassing or degrading to use a bedpan B) incorrect placement of a bedpan has been linked to development of UTIs C) bedpan should not be used if the client needs to defecate D) the bed should be lowered to the lowest height before placing the bedpan
A) 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.
The nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse BEST prepare the client for this procedure? A) position the client in a supine position B) administer a diuretic, as ordered C) have the client rest for 15 minutes before the assessment D) assess the client's need for analgesia
A) position the client in a supine position Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.
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? A) the client has an enlarged prostate B) the diameter of the catheter is too large C) the nurse failed to deflate the retention balloon after pretesting it for integrity D) the client has an occult abscess in the urethra
A) 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 assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true? A) the largest part of a regular bedpan should be placed under the client's buttocks B) a regular bedpan is generally more comfortable for clients than a fracture bedpan C) a fracture bedpan is preferred for urination and a regular bedpan is preferred for defecation D) a fracture bedpan should be used only for clients who have fractures of the femur or lower spine
A) the largest part of a regular bedpan should be placed under the client's buttocks The rounded, smooth upper end of the regular bedpan is designed to be placed under the buttocks. Because a regular bedpan is much larger than a fracture bedpan, it is usually less comfortable. Choice of bedpan is based on client characteristics rather than type of elimination. A fracture bedpan can be used for any client.
A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? A) Withdraw several mL of urine from the port on the collection tubing, using aseptic technique B) empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. C) discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen D) collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic
A) withdraw several mL of urine from the port of the collection tubing, using aseptic technique When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens and aseptic technique. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.
A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? A) withdraw several mL of urine from the port on the collection tubing, using aseptic technique B) empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag C) discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen D) collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic
A) withdraw several mL or urine from the port on the collection tubing, using aseptic technique When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens and aseptic technique. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.
A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? A) withdraw several mL or urine from the port on the collection tubing, using aseptic technique B) empty the collection bag, wait 30 minutes, and then collect the contents of the collections bag C) discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen D) collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic
A) withdraw several mL or urine from the port on the collection tubing, using aseptic technique When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens and aseptic technique. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.
The nurse had an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? A) "Begin the collection when you first urinate in the morning B) "Discard your first urine and begin the collection after that C) "Start collecting the urine with the next time you urinate D) "You will need to have a catheter inserted for this collection
B) "Discard the first urine and begin the collection after that The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.
The nurse is caring for a client who has a history of acute kidney injury. What is an accurate step when caring for the client's hemodialysis access? A) percuss the site to feel for a thrill or vibration B) auscultate over the site with a stethoscope to listen for a bruit C) use the affected arm in an IV must be started to avoid impairment of both arms D) if a thrill is not palpable and/or a bruit is not detectable, assess for these signs in the other arm
B) 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 parent of a 3-year-old boy who has not achieved urinary continence? A) incontinence after the age of 3 years is not normal B) boys may take longer for daytime continence than girls C) boys may walk by 1 year and should be continent by 3 years D) daytime continence is usually not achieved by boys until age 5
B) 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.
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? A) indwelling urethral catheter B) intermittent urethral catheter C) foley catheter D) retention catheter
B) 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.
The 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? A) indwelling urethral catheter B) intermittent urethral catheter C) foley catheter D) retention catheter
B) 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.
The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle (Kegel) exercises will the nurse include? A) loosen the internal muscles used to prevent or interrupt urination B) keep muscles contracted for at least 10 seconds C) relax muscles for a least 5 minutes between repetitions D) perform these exercises two times daily for a week
B) keep muscles contracted for at least 10 seconds Pelvic floor muscle (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 to 4 times daily for 2 weeks to 1 month.
A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? A) calculating the flow rate of urinary output B) monitoring the characteristics of the urinary output C) assessing PVR using a bladder scanner D) palpating the client's bladder region
B) 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.
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? A) moist perineal skin B) reddening perineal skin C) presence of smegma D) absence of discharge
B) reddening 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.
Which urinary care teaching will the nurse provide to a young adult female client? A) wipe from the back to the front B) refrain from douching unless ordered by a health care provider C) if you do not feel like voiding, still strain to make sure the bladder is empty D) drink water more frequently in the morning and evening to facilitate hydration
B) refrain from douching unless ordered by a health care provider Douching is not recommended unless ordered by the health care provider. Female clients should be taught to wipe from the urinary area towards the rectum to decrease the risk for introducing pathogens into the urethra. Straining is not appropriate. Water should be consumed throughout the day, not just in the morning and evening.
The nurse is engaged in collecting a urine specimen for a routine urinalysis from a client with an indwelling catheter. What nursing action has the greatest impact on the accuracy of the testing results? A) using a syringe that holds at least 10 mL B) selecting this particular specimen port site C) wearing gloves for the procedure D) positioning the client as shown
B) selecting this particular specimen port site When it is necessary to collect a urine specimen from a client with an indwelling catheter, the specimen should be obtained from using the special port for specimens. This practice assures aspiration of fresh urine and helps assure result accuracy. A routine urinalysis requires at least 10 ml of urine; assuring a sufficient quantity of urine. Wearing gloves protects the nurse from any contact with the specimen. A client should be placed in position that supports comfort and modesty. While all actions are accurate, appropriately accessing the specimen port has the greatest impact on the accuracy of the urinalysis.
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? A) urge B) stress C) overflow D) functional
B) stress Stress incontinence is caused by pelvic floor muscle weakness or urethral hypermobility. Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contraction. Overflow incontinence occurs when the bladder muscle distends and urine is forced out. Functional incontinence occurs when a physical or psychological impairment impedes continence despite a competent urinary system.
A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? A) reflex incontinence B) stress incontinence C) urge incontinence D) functional incontinence
B) stress incontinence The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to giving birth. Reflex incontinence is caused by damage to motor and sensory tracts in the lower spinal cord secondary to trauma. Urge incontinence is caused by bladder irritation secondary to infection. Functional incontinence is caused by impaired mobility, impaired cognition, or an inability to communicate.
A client's blood urea nitrogen (BUN) test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? A) the client is on a low protein diet B) the client is dehydrated C) the client has a history of osteoarthritis D) the client is lactose intolerant
B) the client is dehydrated The blood urea nitrogen (BUN) test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 ml. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.
A nurse caring for a client with a urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain urine specimen from catheter. After reviewing image, what is the MOST accurate documentation the nurse would use to demonstrate the steps to obtain the urine specimen performed appropriately? A) cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container B) verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well C) obtained urine specimen from drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port D) gathered supplies, checked prescription, collected urine from access port, notified health care provider at completion of procedure
B) verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure will 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.
The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires IMMEDIATE intervention by the experienced nurse? A) "I will place a bath blanket over the client to provide privacy B) "The client will be place in a reclining position with knees bent C) "I will use clean gloves to handle the catheter and other equipment D) "Washing hands before and after the procedure is important
C) "I will use clean gloves to handle the catheter and other equipment Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse.
A client reports an episode of losing control of urination when a bathroom was not close by. The client states, "I am worried this means that I am starting to lose control of my bladder." What is the appropriate nursing response? A) "I agree; please make an appointment with your health care provider B) "This only happened one time, so it's nothing to worry about C) "Let's review your medication history and whether you consume bladder irritants D) "I suggest that you invest in incontinence undergarments
C) "Let's review your medication history and whether you consume bladder irritants Urge incontinence can be aggravated by bladder irritants, such as caffeine or alcohol, and can take place if diuretics are taken in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the health care provider or to recommend incontinence undergarments.
A male client is being transferred to the hospital from a long-term facility with a diagnosis of dehydration and urinary bladder infection. The client's skin is also excoriated from urinary incontinence. Which nursing concern is MOST appropriate for the nurse to include in this client's car plan? A) altered skin integrity related to functional incontinence B) urinary incontinence related to urinary tract infection C) altered skin integrity related to urinary bladder infection and dehydration D) urinary tract infection risk related to dehydration
C) altered skin integrity related to urinary bladder infection and dehydration Altered skin integrity related to urinary bladder infection and dehydration would be the appropriate nursing concern for this client's care plan. The nursing concern is the client's excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary tract infection and urinary incontinence are a medical diagnoses. The altered skin integrity is not related to functional incontinence.
A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included? A) encourage the client to wait to at least 30 minutes before voiding when the urge is felt B) place the client on a schedule to void every 4 hours during the daytime hours C) assist the client to a normal voiding position when possible D) explain to the client that privacy is not important with urination
C) assist the client to a normal voiding position when possible Maintaining a normal voiding pattern would involve having privacy whenever possible, voiding once the urge is felt, and not waiting to urinate. Being in a normal voiding position is important for men and women. The client would not be scheduled to urinate; many people do not have a routine schedule, but void intermittently.
The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterized try using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. A) inflate the balloon with the correct amount of sterile saline B) insert the lubricated catheter into the urethra C) clean each labial fold, then the area directly over the meatus D) discard used supplies E) advance the catheter until there is a return of urine
C) clean each labial fold, then then the area directly over the meatus B) insert the lubricated catheter into the urethra E) advance the catheter until there is a return of urine A) inflate the balloon with the correct amount of sterile saline D) discard used supplies
A client has been NPO (nothing by mouth) after midnight for surgery and the client has received no IV fluids. It is now 1300 and the nurse has asked the client to attempt to void before being transferred to the surgical suite. The nurse should expect the client's urine to be what color? A) pale yellow B) colorless C) dark amber D) tea colored
C) dark amber Urine may be dark amber or orange-brown if it is very concentrated secondary to a decreased fluid intake. Urine is lighter than normal if it is diluted. Foods or drugs can also alter the color of urine. Tea-colored or very dark urine is a sign of dehydration.
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 A) dry the perineal area after urination or defecation from the back to the front B) take baths instead of showers C) Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse D) wear underwear with a cotton crotch E) avoid clothing that is tight and restrictive on the lower half of the body
C) drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse D) wear underwear with a cotton crotch E) avoid clothing that is tight and restrictive on the lower half of the body 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? A) have the client drink 8 ounces of water every 15 minutes for 1 hour B) wipe off some of the ultrasound gel and rescan C) ensure proper positioning of the scanner head and rescan D) place the client on either side and rescan
C) 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.
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? A) remove the catheter every 8 hours, or more often in humid weather B) wipe the penis thoroughly with an alcohol swab and dry thoroughly before application C) fasten the condom securely enough to prevent leakage without constricting blood flow D) ensure the tip of the tubing is touching the tip of the client's penis
C) fasten the condom securely enough to prevent leakage without constricting blood flow Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1 to 2 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.
The nurse is caring for a client with a history of renal insufficiency and type 2 diabetes. Which prescription, if noted in the client's chart, would alert the nurse to discuss with the health care practitioner? A) urine dipstick four times a day B) blueberry juice 10 oz by mouth (PO) daily C) gentamicin 70 mg intramuscular (IM) every 8 hours D) encourage fluids intake 2 to 3 L per day
C) gentamicin 70 mg intramuscular (IM) every 8 hours Gentamicin is known to be nephrotoxic, so the nurse will check with the health care practitioner before administering it. Because glucose acts as an excellent medium for bacteria to grow, a client with diabetes would be monitored for spillage of glucose using a dipstick. Blueberry juice is given to inhibit bacteria from adhering to the urinary bladder. Fluids are encouraged to help flush the renal system.
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? A) checking the blood return in the CVC B) place the client as NPO status C) notifying the health care provider of the assessment findings D) obtaining laboratory studies
C) 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.
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? A) checking for blood return in the CVC B) placing the client as NPO status C) notifying the health care of the assessment findings D) obtaining laboratory studies
C) 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.
A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? A) urge B) reflect C) stress D) total
C) stress Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Other types of incontinence have different causative factors.
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? A) stress incontinence B) functional incontinence C) total incontinence D) overflow incontinence
C) 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.
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? A) "It would be best just to get some adult diapers B) "Let me refer you to a urologist who can help you C) "Don't worry, this is a normal condition for older adults D) "Let's explore structuring activities and toileting breaks
D) "Let's explore structuring activities and toileting breaks 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 parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response? A) "This is extremely abnormal. You will need to see your son's pediatrician." B) "I would only worry about this if you were raising a daughter." C) "It would be appropriate to place your son in incontinence undergarments." D) "Let's review the types of fluids that your child drinks in the morning."
D) "Let's review the types of fluids that your child drinks in the morning." Bladder irritants such as caffeine can cause urge incontinence; it is appropriate to determine whether the child is consuming fluids that contain caffeine. The child's urge incontinence is not extremely abnormal, and this physiological response is not related to gender. It is too soon to refer the client to the health care provider without taking a history, and it is impractical to simply recommend incontinence undergarments.
A female client is diagnosed with a urinary tract infection (UTI) and states this is her second one in the last 6 months. In teaching the client about health promotion, the nurse would include which statement? A) "Fluid intake is not a factor with urinary tract infections B) "Clean the perineal area from back to front when using the bathroom C) "Routine tub baths are fine as long as you are bathing appropriately D) "Try to urinate immediately after sexual intercourse
D) "Try to urinate immediately after sexual intercourse The female client who has repeated UTIs needs health promotion teaching to avoid reoccurrence of these. Urinating immediately after sexual intercourse and drinking an adequate amount of water (eight 8 to 10 oz glasses per day) are important in prevention of UTIs. Showers (rather than tub baths) and cleaning the perineal area from front to back are also measures to help prevent UTIs.
When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine? A) dehydration B) infection C) stasis D) blood
D) blood A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.
The nurse is preparing to irrigate a Foley catheter. What is the nurse's INITIAL action? A) gather equipment and supplies B) assess urine characteristics C) explain the procedure to the client D) check electronic health record for medical order
D) 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.
Which client should the nurse monitor most closely for signs of urinary retention? A) client receiving corticosteroids for acute inflammation B) client who suffered pelvic muscle damage in childbirth 6 months ago C) client who has been diagnosed with early-stage Alzheimer disease D) client with an enlarged prostate
D) client with an enlarged prostate Urinary retention is often related to an enlarging prostate gland. Pelvic damage more commonly leads to incontinence, not retention. Corticosteroids are not associated with urinary retention. Cognitive deficits are more likely to result in incontinence than urinary retention.
A nurse has been asked to speak about health promotion topics for a group of women older than 40 years of age. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the group? A) contract abdominal muscles 10 times per day B) squat dow and them jump up to a standing position C) lie on the floor, raise, then lower your legs 20 times per day D) contract the pubic muscles for 3 seconds, then relax
D) contract the pubic muscles for 3 seconds, then relax Pelvic floor muscle (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 client at a health care facility is being treated for cancer of the bladder. The health care provider uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion? A) inability to control either urinary or bowel elimination B) hygiene measures used to keep meatus and adjacent area of the catheter clean C) use of a catheter to collect urine in a sterile environment D) one or both of the ureters are surgically implanted elsewhere
D) one or both of the ureters are surgically implanted elsewhere The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.
A client at health care facility is being treated for cancer of the bladder. The health care provider uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion? A) inability to control either urinary or bowel elimination B) hygiene measures used to keep meatus and adjacent area of the catheter clean C) use of a catheter to collect urine in a sterile environment D) one or both of the ureters are surgically implanted elsewhere
D) one or both of the ureters are surgically implanted elsewhere The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.
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? A) encouraging the client to stay close to home B) fluid restriction C) indwelling catheterization D) regular toileting routine
D) 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.
Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? A) foley catheter B) suprapubic catheter C) indwelling urethral catheter D) straight catheter
D) straight 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.
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? A) urge B) total C) reflex D) stress
D) stress 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 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? A) the client was treated for kidney stones a few months earlier B) the client has a history of benign prostatic hyperplasia (BPH; prostate enlargement) C) the client has had urinary catheters in place repeatedly during previous admissions D) the client is acutely confused and has been diagnosed with delirium
D) 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.
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) the client may bathe rather than shower, provided the site is covered with gauze B) a dressing should always be worn over the site to avoid leaking C) sterile technique must be observed by the client in the home setting D) the client should avoid wearing tight clothes or belts near the site
D) the client should avoid wearing tight clothes and 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.
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) the client may bathe rather than slower, provided the site is covered with gauze B) a dressing should always be worn over the site to avoid leaking C) sterile technique must be observed by the client in the home setting D) the client should avoid wearing tight clothes or belts near the site
D) 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 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) the client may bathe rather than shower, provided the site is covered with gauze B) a dressing should always be worn over the site to avoid leaking C) sterile technique must be observed by the client in the home setting D) the client should avoid wearing tight clothes or belts near the site
D) 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 is choosing a collection device to collect urine from a non-ambulatory male client. What would be the nurse's BEST choice? A) specimen hat B) large urine collection bag C) bedpan D) urinal
D) urinal A urinal is the best choice to collect urine from a nonambulatory male client. If the client is on strict bed rest or confined to bed due to weakness or disability. the client must be positioned in bed in as close to an upright position as feasible. In most instances, the client is able to place and hold the urinal himself. If he is unable to do so, the nurse should hold the urinal in place while the client urinates or place the urinal and leave the client alone for a few moments. A bedpan is not the best choice for a male client who tend to prefer the bottle-like shape of the urinal, although female clients tend to prefer the shape of a bedpan. A specimen hat is for a commode. A large urine collection bag would be used with an indwelling catheter.
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. A) secure the lid on the specimen container B) clean the area surrounding the urinary meatus with the provided cloth C) submit collected specimen to the health care professional D) void a small amount into the toilet or bedpan E) provide instructions to the client F) void into the provided collection device
E) provide instructions to the client B) clean the area surrounding the urinary meatus with the provided cloth D) void a small amount into the toilet or bedpan F) void into the provided collection device A) secure the lid on the specimen container C) 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.
