CH 36 Taylor

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? The stoma is hard and dry. The stoma is a pale pink color. The stoma is swollen. The stoma is a purple-blue color.

A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should subside with time. A normal stoma should be moist and dark pink to red in color.

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.

The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? The male urethra is more vulnerable to injury during insertion. In the hospital, a clean technique is used for catheter insertion. The catheter is inserted 2″ to 3″ into the meatus. Since it uses a closed system, the risk for urinary tract infection is absent.

Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6″ to 8″. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? Decreased and highly concentrated Decreased and highly dilute Increased and concentrated Increased and dilute

Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.

A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the irrigant will not enter the catheter. What intervention would the nurse appropriately perform next? Apply pressure to the catheter to force the solution into the catheter. Disconnect and reconnect the drainage system quickly. Notify the primary care provider. Change the catheter.

If the irrigation solution will not enter the catheter, the nurse should not force the solution into the catheter; instead, the nurse should notify the primary care provider and prepare to change the catheter.

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? Pouring warm water over the patient's fingers. Having the patient ignore the urge to void until her bladder is full. Using a warm bedpan when the patient feels the urge to void. Stroking the patient's leg or thigh.

Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding.

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Which information is least important for the evaluation process? The incontinence pattern State of physical mobility Medications being taken Age of the patient

Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the plan of care.

A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which teaching points would the nurse include? Select all that apply. Wear underwear with a synthetic crotch. Take baths rather than showers. Drink eight to ten 8-oz glasses of water per day. Drink a glass of water before and after intercourse and void afterwards. Limit caffeine-containing beverages. Drink 10 oz of cranberry or blueberry juice daily.

It is recommended that a healthy adult drink eight to ten 8-oz glasses of fluid daily, limit caffeine because it is irritating to the bladder mucosa, and drink 10 oz of cranberry or blueberry juice daily to help prevent bacteriuria. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse.

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? Teach the patient that incontinence is a normal occurrence with aging. Ask the patient's family to purchase incontinence pads for the patient. Teach the patient to perform Kegel exercises at regular intervals daily. Insert an indwelling catheter to prevent skin breakdown.

Kegel exercises may help a patient regain control of the micturition process. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. An indwelling catheter is the last choice of treatment.

A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination related to maturational enuresis. Based on this diagnosis, for which patient is the nurse caring? An adult older than 65 years of age who is incontinent A child older than 4 years of age who has involuntary urination A 12-month-old child who has involuntary urination A patient with neurologic damage resulting in bladder dysfunction

Maturational enuresis is involuntary urination after an age when continence should be present. A 12-month-old child is not expected to be continent, and incontinence and neurologic damage are not maturational problems.

A nurse is caring for a patient who is taking phenazopyridine (Pyridium, a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish-red today; is there something wrong with me?" What would be the nurse's best response? "This is a normal finding when taking phenazopyridine." "This may be a sign of blood in the urine." "This may be the result of an injury to your bladder." "This is a sign that you are allergic to the medication and must stop it."

Pyridium is noted for turning the urine orange-red; the patient needs to be aware of this.

A nurse is caring for a male patient who had a condom catheter applied following hip surgery. What action would be a priority when caring for this patient? Preventing the tubing from kinking to maintain free urinary drainage Not removing the catheter for any reason Fastening the condom tightly to prevent the possibility of leakage Maintaining bedrest at all times to prevent the catheter from slipping off

The catheter should be allowed to drain freely through tubing that is not kinked. It also should be removed daily to prevent skin excoriation and should not be fastened too tightly or restriction of blood vessels in the area is likely. Confining a patient to bedrest increases the risk for other hazards related to immobility.

A nurse caring for a patient's hemodialysis access documents the following: "5/10/15 0930 Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider? Positive bruit noted. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive thrill noted.

The nurse would report a site that is warm and edematous as this could be a sign of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein. If these are not present, the access may be cutting off. No report of pain is a normal finding.

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. A 78-year-old male patient diagnosed with an enlarged prostate An 83-year-old female patient who is on bedrest A 75-year-old female patient who is diagnosed with vaginal prolapse An 89-year-old male patient who has dementia A 73-year-old female patient who is taking antihistamines to treat allergies A 90-year-old male patient who has difficulty walking to the bathroom

Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.

A nurse is caring for a 56-year-old male patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply Measure the patient's fluid intake and output. Keep the skin around the stoma moist. Empty the appliance frequently. Report any mucous in the urine to the primary care provider. Encourage the patient to look away when changing the appliance. Monitor the return of intestinal function and peristalsis.

When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucous in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.