Chapter 66: Care of Patients with Urinary Problems

A client is prescribed trimethoprim/sulfamethoxazole (Septra) for urinary tract infection (UTI). What does the nurse instruct the client about this therapy? Select all that apply. 1. Disclose any allergies to sulfa drugs before beginning therapy. 2. Wear sunscreen and protective clothing when out in the sun. 3. Monitor the pulse twice daily while taking this drug. 4. Drink a full glass of water with each dose of the drug. 5. Avoid taking the drug within 2 hours of taking an antacid.

1. Disclose any allergies to sulfa drugs before beginning therapy. 2. Wear sunscreen and protective clothing when out in the sun. 4. Drink a full glass of water with each dose of the drug. The nurse should ensure that the client does not have any allergies to sulfa drugs before beginning therapy, since allergies to sulfa drugs are common and may require changing the drug therapy. The client should wear sunscreen and protective clothing when out in the sun because sulfamethoxazole increases sensitivity to the sun and can lead to severe sunburns. The client must consume a full glass of water with each dose because the drug can form crystals that precipitate in the kidney tubules; drinking at least 3 L of fluids daily prevents this complication. The client taking fluoroquinolone is asked to monitor the pulse twice daily as this class of drugs induces serious cardiac dysrhythmias. Fluoroquinolone must not be taken within 2 hours of taking an antacid; antacids containing magnesium or aluminum interfere with drug absorption.

The nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation? Select all that apply. 1. Dysuria 2. Enuresis 3. Frequency 4. Nocturia 5. Urgency 6. Polyuria

1. Dysuria 3. Frequency 4. Nocturia 5. Urgency Dysuria (painful urination), nocturia (frequent urinating at night), urgency (having the urge to urinate quickly), and frequency are symptoms of UTI. Enuresis (bed-wetting) and polyuria (increased amounts of urine production) are not signs of a UTI.

What nonsurgical methods does the nurse teach the client to manage stress incontinence? Select all that apply. 1. Reduce excess body weight. 2. Walk to strengthen pelvic muscles. 3. Perform Kegel exercises. 4. Use artificial sweeteners instead of sugar. 5. Practice vaginal cone therapy.

1. Reduce excess body weight. 3. Perform Kegel exercises. 5. Practice vaginal cone therapy. The client with stress incontinence should reduce excess weight because increased abdominal pressure aggravates stress incontinence. Kegel exercise therapy strengthens the muscles of the pelvic floor, and weighted vaginal cones are used to strengthen pelvic muscles and decrease stress incontinence. Walking is a good exercise; however, it does not help to increase pelvic strength. The client must avoid foods that irritate the bladder such as artificial sweeteners, alcohol, nicotine, citrus, and caffeine.

What clinical findings does the nurse attribute to the presence of kidney stones? Select all that apply. 1. Smoky urine 2. Odorless urine 3. Increased serum calcium 4. Increased serum phosphate 5. Urine pH of 6

1. Smoky urine 3. Increased serum calcium 4. Increased serum phosphate Smoky or rusty urine is common in clients with kidney stones, indicating hematuria. Increases in serum calcium and phosphate levels indicate that excess minerals are present and may contribute to stone formation. The urine generally has an odor, indicating infection. Normal urine is alkaline, with a pH between 5 and 6. If urine contains uric acid or cystine stones, it is highly acidic. If urine contains calcium phosphate and struvite stones, it is alkaline.

What method of emptying the bladder is helpful for a client with a large cystocele? 1. Splinting 2. Credé method 3. Double-voiding 4. Valsalva maneuver

1. Splinting The client with a large cystocele or prolapse of the bladder into the vagina may use splinting to reduce renal urinary incontinence. This is achieved by inserting fingers into the vagina and lifting the cystocele to urinate. The client using the Credé method presses over the bladder area to increase pressure. The client may also trigger nerve stimulation by tugging at the pubic hair or massaging the genital area. In the double-voiding technique, the client empties the bladder once and then attempts a second voiding within a few minutes. The Valsalva maneuver is a breathing technique that increases chest and abdominal pressure. Increased pressure is directed toward the bladder during exhalation.

The nurse is teaching a client with a neurogenic bladder to use intermittent self-catheterization for bladder emptying. Which client statement indicates a need for further clarification? 1. "A small-lumen catheter will help prevent injury to my urethra." 2. "I will use a new, sterile catheter each time I do the procedure." 3. "My family members can be taught to help me if I need it." 4. "Proper handwashing before I start the procedure is very important."

2. "I will use a new, sterile catheter each time I do the procedure." Catheters are cleaned and reused. With proper handwashing and cleaning of the catheter, no increase in bacterial complications has been shown. Catheters are replaced when they show signs of deteriorating. The smallest lumen possible and the use of a lubricant help reduce urethral trauma to this sensitive mucous tissue. Research shows that family members in the home can be taught to perform straight catheterizations using a clean (rather than a sterile) catheter with good outcomes. Proper handwashing is extremely important in reducing the risk for infection in clients who use intermittent self-catheterization and is a principle that should be stressed.

The nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first? 1. 26-year-old admitted 2 days ago with urosepsis with an oral temperature of 99.4° F (37.4° C) 2. 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours 3. 32-year-old admitted with hematuria and possible bladder cancer who is scheduled for cystoscopy 4. 40-year-old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed

2. 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours Anuria may indicate urinary obstruction at the bladder neck or urethra and is an emergency because obstruction can cause acute kidney failure. The client who has been receiving morphine sulfate may be oversedated and may not be aware of any discomfort caused by bladder distention. The 26-year-old admitted with urosepsis and slight fever, the 32-year-old scheduled for cystoscopy, and the 40-year-old with noninfectious urethritis are not at immediate risk for complications or deterioration.

During assessment of a client, what finding does the nurse associate with the presence of kidney stones? 1. Oliguria 2. Flank pain 3. Dysuria 4. Flank pain extending to the scrotum

2. Flank pain The major manifestation of kidney stones is renal colic, which begins suddenly and is described as "unbearable." Flank pain indicates that the stone is in the kidney or the upper ureter. Oliguria, or scant urine output, indicates an obstruction at the bladder neck or urethra. Dysuria and frequency occur when the stone reaches the bladder and causes irritation. Flank pain extending to the scrotum suggests that the stones are in the ureters or bladder. The pain is most intense when the stone is moving or when the ureter is obstructed.

What complication may the nurse expect in an older client with an indwelling catheter for urinary continence? 1. Skin breakdown 2. Risk for infection 3. Damage to tissues 4. Urine retention

2. Risk for infection An indwelling catheter increases the risk for infection in a client. An indwelling catheter can help protect the skin and reduce the risk of skin breakdown caused by urinary incontinence. Applied devices, such as intravaginal pessaries for women and penile clamps for men, can cause tissue damage. An indwelling catheter completely drains the bladder, so the client does not have urinary retention.

A client is prescribed prophylactic immunotherapy with intravesical instillation of bacille Calmette-Guérin (BCG) to prevent recurrence of bladder tumor. What does the nurse inform the client about this therapy? 1. The procedure is done in an inpatient setting. 2. The BCG virus compound is allowed to dwell in the bladder for 2 hours. 3. Flush the toilet three times after use. 4. Dispose of clothing that comes in contact with urine in 24 hours.

2. The BCG virus compound is allowed to dwell in the bladder for 2 hours. The BCG virus compound is allowed to dwell in the bladder for 2 hours. Live virus will be excreted when the client urinates. The instillation procedure is done in an outpatient setting. The client must not share the toilet with other household members for 24 hours after instillation; the toilet must be flushed and cleaned with a solution of 10% liquid bleach. The client must wash all clothing that has come into contact with urine during the 24 hours after instillation separately with 10% liquid bleach.

The nurse in the urology clinic is providing teaching for a female client with cystitis. Which instructions does the nurse include in the teaching plan? Select all that apply. 1. Cleanse the perineum from back to front after using the bathroom. 2. Try to take in 64 ounces of fluid each day. 3. Be sure to complete the full course of antibiotics. 4. If urine remains cloudy, call the clinic. 5. Expect some flank discomfort until the antibiotic has worked.

2. Try to take in 64 ounces of fluid each day. 3. Be sure to complete the full course of antibiotics. 4. If urine remains cloudy, call the clinic. Between 64 and 100 ounces (2-3 liters) of fluid should be taken daily to dilute bacteria and prevent infection. Not completing the course of antibiotics could suppress the bacteria, but would not destroy all bacteria, causing the infection to resurface. For persistent symptoms of infection, the client should contact the provider. The perineal area should be cleansed from front to back or "clean to dirty" to prevent infection. Cystitis produces suprapubic symptoms; flank pain occurs with infection or inflammation of the kidney.

The nurse is caring for a client who has pyuria. What does the urinalysis reveal in this client? 1. Kidney stones. 2. White blood cells in the urine. 3. Red blood cells in the urine. 4. Heavy bacteria in the urine.

2. White blood cells in the urine. Urinalysis showing pyuria means that the client has white blood cells in the urine without a large number of bacteria.

The nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective? 1. "I must avoid drinking carbonated beverages." 2. "I need to douche vaginally once a week." 3. "I should drink 2½ liters of fluid every day." 4. "I will not drink fluids after 8 pm each evening."

3. "I should drink 2½ liters of fluid every day." Drinking 2½ liters of fluid a day flushes out the urinary system and helps reduce the risk for cystitis. Avoiding carbonated beverages is not necessary to reduce the risk for cystitis. Douching is not a healthy behavior because it removes beneficial organisms as well as the harmful ones. Avoiding fluids after 8 pm would help prevent nocturia but not cystitis. It is recommended that clients with incontinence problems limit their late-night fluid intake to 120 mL.

A 53-year-old postmenopausal woman reports "leaking urine" when she laughs, and is diagnosed with stress incontinence. What does the nurse tell the client about how certain drugs may be able to help with her stress incontinence? 1. "They can relieve your anxiety associated with incontinence." 2. "They help your bladder to empty." 3. "They may be used to improve urethral resistance." 4. "They decrease your bladder's tone."

3. "They may be used to improve urethral resistance." Bladder pressure is greater than urethral resistance; drugs may be used to improve urethral resistance. Relieving anxiety has not been shown to improve stress incontinence. No drugs have been shown to promote bladder emptying, and this is not usually the problem with stress incontinence. Emptying the bladder is accomplished by the individual, or if that is not possible, by using a catheter. Decreasing bladder tone would not be a desired outcome for a woman with incontinence.

A client is prescribed estrogen therapy for urinary incontinence. What does the nurse teach the client about this therapy? 1. Change positions slowly, especially in the mornings. 2. Report urine output that is significantly lower than fluid intake. 3. A thin application of cream is adequate. 4. Use hard candy to moisten the mouth.

3. A thin application of cream is adequate. Teach the client that a thin application of estrogen cream is all that is needed. The client taking tricyclic antidepressants must change positions slowly, especially in the mornings, because these drugs cause dizziness, orthostatic hypotension, and increase the risk for falls. The client taking antispasmodics or anticholinergics should report urine output that is significantly lower than fluid intake as these drugs cause urine retention. Dry mouth is another side effect of antispasmodics and anticholinergics; the client can use hard candy to moisten the mouth.

A cognitively impaired client has urge incontinence. Which method for achieving continence does the nurse include in the client's care plan? 1. Bladder training 2. Credé method 3. Habit training 4. Kegel exercises

3. Habit training Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired client because the caregiver is responsible for helping the client to a toilet on a scheduled basis. Bladder training, the Credé method, and learning Kegel exercises require that the client be alert, cooperative, and able to assist with his or her own training.

The certified Wound, Ostomy, and Continence Nurse (CWOCN) or enterostomal therapist (ET) teaches a client who has had a cystectomy about which care principles for the client's postdischarge activities? 1. Nutritional and dietary care 2. Respiratory care 3. Stoma and pouch care 4. Wiping from front to back (asepsis)

3. Stoma and pouch care The enterostomal therapist demonstrates external pouch application, local skin care, pouch care, methods of adhesion, and drainage mechanisms. The registered dietitian (RD) teaches the cystectomy client about nutritional care. The respiratory therapist teaches the cystectomy client about respiratory care. The client with a cystectomy does not require instruction about front-to-back wiping.

A client is ordered phenazopyridine (Prodium) to reduce bladder pain and burning on urination. What does the nurse teach the client about this drug regimen? 1. Report if the urine turns red. 2. Report blurred vision. 3. Take the drug with a meal. 4. Wear dark glasses in sunlight.

3. Take the drug with a meal. The client should take the drug with a meal to prevent gastrointestinal disturbances. The client need not report if the urine turns red or orange because this is an expected response to the drug. The client taking antispasmodics for relieving bladder spasms is asked to report blurred vision,which is a manifestation of toxicity. The client taking antispasmodics, not analgesics, is asked to wear dark glasses in sunlight as the drug dilates the pupil and increases eye sensitivity to light.

The nurse is teaching a client who is scheduled for a neobladder and a Kock's pouch. Which client statement indicates a correct understanding of these procedures? 1 . "If I restrict my oral intake of fluids, the adjustment will be easier." 2. "I must go to the restroom more often because my urine will be excreted through my anus." 3. "I need to wear loose-fitting pants so the urine can flow into my ostomy bag." 4. "I will have to drain my pouch with a catheter."

4. "I will have to drain my pouch with a catheter." For the client with a neobladder and a Kock's pouch, urine is collected in a pouch and is drained with the use of a catheter. Fluids should not be restricted. A neobladder does not require the use of an ostomy bag.

The nurse is teaching a client about pelvic muscle exercises. What information does the nurse include? 1. "For the best effect, perform all of your exercises while you are seated on the toilet." 2. "Limit your exercises to 5 minutes twice a day, or you will injure yourself." 3. "Results should be visible to you within 72 hours." 4. "You know that you are exercising correct muscles if you can stop urine flow in midstream."

4. "You know that you are exercising correct muscles if you can stop urine flow in midstream." When the client can start and stop the urine stream, the pelvic muscles are being used. Pelvic muscle exercises can be performed anywhere and should be performed more often than 5 minutes twice daily. Noticeable results take several weeks.

The health care provider requests phenazopyridine (Pyridium) for a client with cystitis. What does the nurse tell the client about the drug? 1. "It will act as an antibacterial drug." 2. "This drug will treat your infection, not the symptoms of it." 3. "You need to take the drug on an empty stomach." 4. "Your urine will turn red or orange while on the drug."

4. "Your urine will turn red or orange while on the drug." Phenazopyridine will turn the client's urine red or orange. Clients should be warned about this effect of the drug because it will be alarming to them if they are not informed, and care should be taken because it will stain undergarments. Phenazopyridine reduces bladder pain and burning by exerting a local analgesic/anesthetic effect on the mucosa of the urinary tract. It does treat the symptoms of bladder infection; it has no antibacterial action. Phenazopyridine should be taken with a meal or immediately after eating.

Which client does the nurse manager on the medical unit assign to an experienced LPN/LVN? 1. 42-year-old with painless hematuria who needs an admission assessment 2. 46-year-old scheduled for cystectomy who needs help in selecting a stoma site 3. 48-year-old receiving intravesical chemotherapy for bladder cancer 4. 55-year-old with incontinence who has intermittent catheterization prescribed

4. 55-year-old with incontinence who has intermittent catheterization prescribed Insertion of catheters is within the education and legal scope of practice for LPN/LVNs. Admission assessments and intravesical chemotherapy should be done by an RN. Preoperative preparation for cystectomy and stoma site selection should be done by an RN and either a Certified Wound, Ostomy, and Continence Nurse (CWOCN) or an enterostomal therapy (ET) nurse.

What clinical finding in a postmenopausal client with urethritis does the nurse attribute to low estrogen levels? 1. The urinalysis indicates pyuria. 2. The urethral culture is positive for bacteria. 3. The urinalysis indicates presence of bacteria. 4. A pelvic examination shows tissue changes.

4. A pelvic examination shows tissue changes. A pelvic examination of a postmenopausal client shows tissue changes due to low estrogen. The client with urethritis does not have pyuria or white blood cells (WBCs) in the urine. The urethral culture and urinalysis is usually negative for bacteria. These clients may have improvement in their urethral symptoms with the use of estrogen vaginal cream.

The nurse is caring for a client with cystitis. What does the nurse ask the client to include in the diet as part of nutritional therapy? 1. Carbonated beverages 2. Tomato products 3. Caffeine 4. Cranberry juice

4. Cranberry juice The client with cystitis should consume 50 mL of concentrated cranberry juice daily because it is known to decrease the ability of bacteria to adhere to the epithelial cells lining the urinary tract, decreasing the incidence of symptomatic urinary tract infections in some clients. Cranberry juice must be consumed for 3 to 4 weeks to be effective. Caffeine, carbonated beverages, and tomato products must be avoided to decrease bladder irritation during cystitis.

What does the nurse teach a client to do to decrease the risk for urinary tract infection (UTI)? 1. Limit fluid intake. 2. Increase caffeine consumption. 3. Limit sugar intake. 4. Drink about 3 liters of fluid daily.

4. Drink about 3 liters of fluid daily. Drinking about 3 liters of fluid daily, if another medical problem does not require fluid restriction, helps prevent dehydration and UTIs. Fluids flush the system and should not be limited. Increased caffeine intake and limiting sugar intake will not prevent UTIs.

In what location would the nurse expect to find infection in a client with acute pyelonephritis? 1. Urethra 2. Urinary bladder 3. Prostate gland 4. Kidneys

4. Kidneys Acute pyelonephritis is a kidney infection. Urinary tract infections are described by their location in the tract. Urethritis is an acute infection in the urethra, cystitis in the bladder, and prostatitis in the prostate gland.

What procedure does the nurse expect the health care provider to prescribe for the removal of a large, impacted stone in a client's kidney? 1. Lithotripsy 2. Stenting 3. Pyelolithotomy 4. Nephrolithotomy

4. Nephrolithotomy Nephrolithotomy, an open surgical procedure, is often prescribed to remove a large, impacted stone in the kidney. This method is performed if all other procedures fail and there is a possible risk for a lasting injury to the ureter or kidney. Lithotripsy is the use of sound, laser, or dry shock waves to break stones into small fragments. Stenting is a minimally invasive procedure performed by placing a stent in the ureter by ureteroscopy. The stent dilates the ureter, enlarging the passageway for the stone or stone fragments. Pyelolithotomy is an open surgical procedure to remove stones in the kidney pelvis.

A client reports experiencing involuntary loss and constant dribbling of urine due to an enlarged prostate. How does the nurse document this incontinence? 1. Stress incontinence 2. Urge incontinence 3. Reflex incontinence 4. Overflow incontinence

4. Overflow incontinence This client's condition is known as overflow incontinence. The urethra in the client is obstructed due to the enlarged prostate; the urethra fails to relax sufficiently to allow urine to flow, resulting in incomplete bladder emptying or complete urinary retention. Loss of urine following physical exertion, cough, or sneeze is documented as stress incontinence. Stress incontinence occurs due to intrinsic sphincter deficiency or acquired anatomic damage to the urethral sphincter. The client with urge incontinence experiences an involuntary loss of urine with a strong desire to urinate. The client with reflex incontinence has a post-void residual less than 50 mL.

A client with diabetes has all of the following changes after a percutaneous nephrolithotomy procedure. Which change is most important for the nurse need to immediately report to the health care provider? A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula B. A point-of-care blood glucose of 150 mg/dL and client report of thirst C. A decreased hematocrit by 1% (compared with preoperative values and hematuria D. An oral temperature of 38° C (101° F) and cloudiness of urine draining from the nephrostomy tube right after IV administration of a broad-spectrum antibiotic

A

13. A nurse cares for a client admitted from a nursing home after several recent falls. What prescription should the nurse complete first? a. Obtain urine sample for culture and sensitivity. b. Administer intravenous antibiotics. c. Encourage protein intake and additional fluids. d. Consult physical therapy for gait training.

A Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often urinary tract infection (UTI) symptoms in older adults are atypical, and a UTI may present with new onset of confusion or falling. The urine sample should be obtained before starting antibiotics. Dietary requirements and gait training should be implemented after obtaining the urine sample.

10. After teaching a client with a history of renal calculi, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I should drink at least 3 liters of fluid every day. b. I will eliminate all dairy or sources of calcium from my diet. c. Aspirin and aspirin-containing products can lead to stones. d. The doctor can give me antibiotics at the first sign of a stone.

A Dehydration contributes to the precipitation of minerals to form a stone. Although increased intake of calcium causes hypercalcemia and leads to excessive calcium filtered into the urine, if the client is well hydrated the calcium will be excreted without issues. Dehydration increases the risk for supersaturation of calcium in the urine, which contributes to stone formation. The nurse should encourage the client to drink more fluids, not decrease calcium intake. Ingestion of aspirin or aspirin-containing products does not cause a stone. Antibiotics neither prevent nor treat a stone.

6. A nurse cares for adult clients who experience urge incontinence. For which client should the nurse plan a habit training program? a. A 78-year-old female who is confused b. A 65-year-old male with diabetes mellitus c. A 52-year-old female with kidney failure d. A 47-year-old male with arthritis

A For a bladder training program to succeed in a client with urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times. The other clients may benefit from another type of bladder training.

5. After teaching a client who has stress incontinence, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I will limit my total intake of fluids. b. I must avoid drinking alcoholic beverages. c. I must avoid drinking caffeinated beverages. d. I shall try to lose about 10% of my body weight.

A Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

16. A nurse obtains the health history of a client with a suspected diagnosis of bladder cancer. Which question should the nurse ask when determining this clients risk factors? a. Do you smoke cigarettes? b. Do you use any alcohol? c. Do you use recreational drugs? d. Do you take any prescription drugs?

A Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, recreational drug use, and prescription drug use (except medications that contain phenacetin) are not known to increase the risk of developing bladder cancer.

18. A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this clients teaching? a. Use a second form of birth control while on this medication. b. You will experience increased menstrual bleeding while on this drug. c. You may experience an irregular heartbeat while on this drug. d. Watch for blood in your urine while taking this medication.

A The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

23. A nurse assesses a client who presents with renal calculi. Which question should the nurse ask? a. Do any of your family members have this problem? b. Do you drink any cranberry juice? c. Do you urinate after sexual intercourse? d. Do you experience burning with urination?

A There is a strong association between family history and stone formation and recurrence. Nephrolithiasis is associated with many genetic variations; therefore, the nurse should ask whether other family members have also had renal stones. The other questions do not refer to renal calculi but instead are questions that should be asked of a client with a urinary tract infection.

7. A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Finish the prescribed antibiotic even if you are feeling better. b. Drink at least 3 liters of fluid each day. c. The bruising on your back may take several weeks to resolve. d. Report any blood present in your urine. e. It is normal to experience pain and difficulty urinating.

A, B, C The client should be taught to finish the prescribed antibiotic to ensure that he or she does not get a urinary tract infection. The client should drink at least 3 liters of fluid daily to dilute potential stone-forming crystals, prevent dehydration, and promote urine flow. After lithotripsy, the client should expect bruising that may take several weeks to resolve. The client should also experience blood in the urine for several days. The client should report any pain, fever, chills, or difficulty with urination to the provider as these may signal the beginning of an infection or the formation of another stone.

1. A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. How much water do you drink every day? b. Do you take estrogen replacement therapy? c. Does anyone in your family have a history of cystitis? d. Are you on steroids or other immune-suppressing drugs? e. Do you drink grapefruit juice or orange juice daily?

A, B, D Fluid intake, estrogen levels, and immune suppression all can increase the chance of recurrent cystitis. Family history is usually insignificant, and cranberry juice, not grapefruit or orange juice, has been found to increase the acidic pH and reduce the risk for bacterial cystitis.

5. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestation? (Select all that apply.) a. Stress incontinence Urine loss with physical exertion b. Urge incontinence Large amount of urine with each occurrence c. Functional incontinence Urine loss results from abnormal detrusor contractions d. Overflow incontinence Constant dribbling of urine e. Reflex incontinence Leakage of urine without lower urinary tract disorder

A, B, D Stress incontinence is a loss of urine with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with an abrupt and strong urge to void and usually has a large amount of urine released with each occurrence. Overflow incontinence occurs with bladder distention and results in a constant dribbling of urine. Functional incontinence is the leakage of urine caused by factors other than a disorder of the lower urinary tract. Reflex incontinence results from abnormal detrusor contractions from a neurologic abnormality.

6. A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this clients dietary teaching? (Select all that apply.) a. Limit your intake of food high in animal protein. b. Read food labels to help minimize your sodium intake. c. Avoid spinach, black tea, and rhubarb. d. Drink white wine or beer instead of red wine. e. Reduce your intake of milk and other dairy products.

A, B, E Clients with calcium phosphate urinary stones should be taught to limit the intake of foods high in animal protein, sodium, and calcium. Clients with calcium oxalate stones should avoid spinach, black tea, and rhubarb. Clients with uric acid stones should avoid red wine.

8. A nurse teaches a female client who has stress incontinence. Which statements should the nurse include about pelvic muscle exercises? (Select all that apply.) a. When you start and stop your urine stream, you are using your pelvic muscles. b. Tighten your pelvic muscles for a slow count of 10 and then relax for a slow count of 10. c. Pelvic muscle exercises should only be performed sitting upright with your feet on the floor. d. After you have been doing these exercises for a couple days, your control of urine will improve. e. Like any other muscle in your body, you can make your pelvic muscles stronger by contracting them.

A, B, E The client should be taught that the muscles used to start and stop urination are pelvic muscles, and that pelvic muscles can be strengthened by contracting and relaxing them. The client should tighten pelvic muscles for a slow count of 10 and then relax the muscles for a slow count of 10, and perform this exercise 15 times while in lying-down, sitting-up, and standing positions. The client should begin to notice improvement in control of urine after several weeks of exercising the pelvic muscles.

2. A nurse teaches a client about self-catheterization in the home setting. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Wash your hands before and after self-catheterization. b. Use a large-lumen catheter for each catheterization. c. Use lubricant on the tip of the catheter before insertion. d. Self-catheterize at least twice a day or every 12 hours. e. Use sterile gloves and sterile technique for the procedure. f. Maintain a specific schedule for catheterization.

A, C, F The key points in self-catheterization include washing hands, using lubricants, and maintaining a regular schedule to avoid distention and retention of urine that leads to bacterial growth. A smaller rather than a larger lumen catheter is preferred. The client needs to catheterize more often than every 12 hours. Self-catheterization in the home is a clean procedure.

What information will the nurse provide to a client who is scheduled for extracorporeal shock wave lithotripsy? Select all that apply. A. "Your urine will be strained after the procedure." B. "Be sure to finish all of your antibiotics." C. "Immediately call the health care provider if you notice bruising." D. "Remember to drink at least 3 liters of fluid a day to promote urine flow." E. "You will need to change the incisional dressing once a day."

A. "Your urine will be strained after the procedure." B. "Be sure to finish all of your antibiotics." D. "Remember to drink at least 3 liters of fluid a day to promote urine flow." After lithotripsy, urine is strained to monitor the passage of stone fragments. Clients must finish the entire antibiotic prescription to decrease the risk of developing a urinary tract infection. Drinking at least 3 L of fluid a day dilutes potential stone-forming crystals, prevents dehydration, and promotes urine flow. Bruising on the flank of the affected side is expected after lithotripsy as a result of the shock waves that break the stone into small fragments. The client must notify the health care provider if he or she develops pain, fever, chills, or difficulty with urination because these signs and symptoms may signal the beginning of an infection or the formation of another stone. There is no incision with extracorporeal shock wave lithotripsy. There may be a small incision when intracorporeal lithotripsy is performed.

2. A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a clients white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the unlicensed assistive personnel (UAP) to strain the clients urine for renal calculi. d. Assess the client for a potential allergic reaction and anaphylactic shock.

B An increase in band cells creates a shift to the left. A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The nurse would not need to strain urine for stones. Allergic reactions are associated with elevated eosinophil cells, not band cells.

22. A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention? a. A 29-year-old client after a difficult vaginal delivery Habit training b. A 58-year-old postmenopausal client who is not taking estrogen therapy Electrical stimulation c. A 64-year-old female with Alzheimers-type senile dementia Bladder training d. A 77-year-old female who has difficulty ambulating Exercise therapy

B Exercise therapy and electrical stimulation are used for clients with stress incontinence related to childbirth or low levels of estrogen after menopause. Exercise therapy increases pelvic wall strength; it does not improve ambulation. Physical therapy and a bedside commode would be appropriate interventions for the client who has difficulty ambulating. Habit training is the type of bladder training that will be most effective with cognitively impaired clients. Bladder training can be used only with a client who is alert, aware, and able to resist the urge to urinate.

7. After delegating care to an unlicensed assistive personnel (UAP) for a client who is prescribed habit training to manage incontinence, a nurse evaluates the UAPs understanding. Which action indicates the UAP needs additional teaching? a. Toileting the client after breakfast b. Changing the clients incontinence brief when wet c. Encouraging the client to drink fluids d. Recording the clients incontinence episodes

B Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The UAP should continue to toilet the client after meals, encourage the client to drink fluids, and record incontinent episodes.

3. A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How should the nurse respond? a. Your immune system becomes less effective as you age. b. Low estrogen levels can make the tissue more susceptible to infection. c. You should be more careful with your personal hygiene in this area. d. It is likely that you have an untreated sexually transmitted disease.

B Low estrogen levels decrease moisture and secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

20. An emergency department nurse assesses a client with a history of urinary incontinence who presents with extreme dry mouth, constipation, and an inability to void. Which question should the nurse ask first? a. Are you drinking plenty of water? b. What medications are you taking? c. Have you tried laxatives or enemas? d. Has this type of thing ever happened before?

B Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to assess the clients medication list to determine whether the client is taking an anticholinergic medication. If he or she is taking anticholinergics, the nurse should further assess the clients manifestations to determine if they are related to a simple side effect or an overdose. The other questions are not as helpful to understanding the current situation.

21. A nurse teaches a client who is starting urinary bladder training. Which statement should the nurse include in this clients teaching? a. Use the toilet when you first feel the urge, rather than at specific intervals. b. Try to consciously hold your urine until the scheduled toileting time. c. Initially try to use the toilet at least every half hour for the first 24 hours. d. The toileting interval can be increased once you have been continent for a week.

B The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

24. A nurse assesses a male client who is recovering from a urologic procedure. Which assessment finding indicates an obstruction of urine flow? a. Severe pain b. Overflow incontinence c. Hypotension d. Blood-tinged urine

B The most common manifestation of urethral stricture after a urologic procedure is obstruction of urine flow. This rarely causes pain and has no impact on blood pressure. The client may experience overflow incontinence with the involuntary loss of urine when the bladder is distended. Blood in the urine is not a manifestation of the obstruction of urine flow.

12. A nurse assesses a client who is recovering from extracorporeal shock wave lithotripsy for renal calculi. The nurse notes an ecchymotic area on the clients right lower back. Which action should the nurse take? a. Administer fresh-frozen plasma. b. Apply an ice pack to the site. c. Place the client in the prone position. d. Obtain serum coagulation test results.

B The shock waves from lithotripsy can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising. Although coagulation test results and fresh-frozen plasma are used to assess and treat bleeding disorders, ecchymosis after this procedure is not unusual and does not warrant a higher level of intervention. Changing the clients position will not decrease bleeding.

For which adverse drug effects does the nurse assess in a client who is hospitalized for an acute problem and is also prescribed an anticholinergic drug to manage incontinence? Select all that apply. A. Insomnia B. Blurred vision C. Constipation D. Dry mouth E. Loss of sphincter control F. Increased sweating G. Worsening mental function H. Hypotension

B, C, D, G

4. A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems. c. Perform a bladder scan to assess post-void residual. d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.

B, E Clients who are severely immunocompromised or who have diabetes mellitus are more prone to fungal UTIs. The nurse should assess for these factors by asking about medical history, current medical problems, and the current medication list. A physical examination and a post-void residual may be needed, but not until further information is obtained indicating that these examinations are necessary. Travel to foreign countries probably would not be important because, even if exposed, the client needs some degree of compromised immunity to develop a fungal UTI.

3. A nurse teaches clients about the difference between urge incontinence and stress incontinence. Which statements should the nurse include in this education? (Select all that apply.) a. Urge incontinence involves a post-void residual volume less than 50 mL. b. Stress incontinence occurs due to weak pelvic floor muscles. c. Stress incontinence usually occurs in people with dementia. d. Urge incontinence can be managed by increasing fluid intake. e. Urge incontinence occurs due to abnormal bladder contractions.

B, E Clients who suffer from stress incontinence have weak pelvic floor muscles or urethral sphincter and cannot tighten their urethra sufficiently to overcome the increased detrusor pressure. Stress incontinence is common after childbirth, when the pelvic muscles are stretched and weakened from pregnancy and delivery. Urge incontinence occurs in people who cannot suppress the contraction signal from the detrusor muscle. Abnormal detrusor contractions may be a result of neurologic abnormalities including dementia, or may occur with no known abnormality. Post-void residual is associated with reflex incontinence, not with urge incontinence or stress incontinence. Management of urge incontinence includes decreasing fluid intake, especially in the evening hours.

A 70-year-old client is seeing his primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. A five-pack year history of smoking 45 years ago B. Difficulty starting and stopping the urine stream C. A 30-year occupation as a long-distance truck driver D. A recent colon cancer diagnosis in his 72-year-old brother

C

15. A nurse assesses a client with bladder cancer who is recovering from a complete cystectomy with ileal conduit. Which assessment finding should alert the nurse to urgently contact the health care provider? a. The ileostomy is draining blood-tinged urine. b. There is serous sanguineous drainage present on the surgical dressing. c. The ileostomy stoma is pale and cyanotic in appearance. d. Oxygen saturations are 92% on room air.

C A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis. Blood-tinged urine and serous sanguineous drainage are expected after this type of surgery. Oxygen saturation of 92% on room air is at the low limit of normal.

9. A confused client with pneumonia is admitted with an indwelling catheter in place. During interdisciplinary rounds the following day, which question should the nurse ask the primary health care provider? a. Do you want daily weights on this client? b. Will the client be able to return home? c. Can we discontinue the indwelling catheter? d. Should we get another chest x-ray today?

C An indwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

1. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure

C Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is not using hormone replacement therapy.

4. After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will not take this drug with food or milk. b. If I think I am pregnant, I will stop the drug. c. An orange color in my urine should not alarm me. d. I will drink two glasses of cranberry juice daily.

C Phenazopyridine discolors urine, most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing. Phenazopyridine is safe to take if the client is pregnant. There are no dietary restrictions or needs while taking this medication.

26. A nurse provides phone triage to a pregnant client. The client states, I am experiencing a burning pain when I urinate. How should the nurse respond? a. This means labor will start soon. Prepare to go to the hospital. b. You probably have a urinary tract infection. Drink more cranberry juice. c. Make an appointment with your provider to have your infection treated. d. Your pelvic wall is weakening. Pelvic muscle exercises should help.

C Pregnant clients with a urinary tract infection require prompt and aggressive treatment because cystitis can lead to acute pyelonephritis during pregnancy. The nurse should encourage the client to make an appointment and have the infection treated. Burning pain when urinating does not indicate the start of labor or weakening of pelvic muscles.

25. A nurse cares for a client with urinary incontinence. The client states, I am so embarrassed. My bladder leaks like a young childs bladder. How should the nurse respond? a. I understand how you feel. I would be mortified. b. Incontinence pads will minimize leaks in public. c. I can teach you strategies to help control your incontinence. d. More women experience incontinence than you might think.

C The nurse should accept and acknowledge the clients concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the clients concerns with the use of pads or stating statistics about the occurrence of incontinence.

A 25-year-old sexually active female client diagnosed with cystitis tells the nurse that she doesn't understand why she has these infections yearly because she tries to avoid them by drinking very little at work so she doesn't have to use the "dirty" public toilet. Which suggestions or actions by the nurse are most likely to help this client reduce her risk for cystitis? Select all that apply. A. Reinforce her choice to avoid using a public toilet. B. Teach her to shower immediately after having sexual intercourse. C. Suggest that she drink at least 2-3 L of fluid throughout the day. D. Urge her to change her method of birth control from oral contraceptives to a barrier method. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before having intercourse.

C, E, F, G

For which hospitalized client does the nurse recommend the ongoing use of a urinary catheter? A. 35-year-old woman who was admitted with a splenic laceration and femur fracture (closed repair completed) following a car crash B. 48-year-old man who has established paraplegia and is admitted for pneumonia C. 61-year-old woman who is admitted following a fall at home and has new-onset dysrhythmia D. 74-year-old man who has lung cancer with brain metastasis and is being transitioned to hospice for end-of-life care

D

19. A nurse teaches a client with functional urinary incontinence. Which statement should the nurse include in this clients teaching? a. You must clean around your catheter daily with soap and water. b. Wash the vaginal weights with a 10% bleach solution after each use. c. Operations to repair your bladder are available, and you can consider these. d. Buy slacks with elastic waistbands that are easy to pull down.

D Functional urinary incontinence occurs as the result of problems not related to the clients bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

8. A nurse plans care for a client with overflow incontinence. Which intervention should the nurse include in this clients plan of care to assist with elimination? a. Stroke the medial aspect of the thigh. b. Use intermittent catheterization. c. Provide digital anal stimulation. d. Use the Valsalva maneuver.

D In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding. Stroking the medial aspect of the thigh or providing digital anal stimulation requires the reflex arc to be intact to initiate elimination. Due to the high risk for infection, intermittent catheterization should only be implemented when other interventions are not successful.

11. A nurse cares for a client who has kidney stones from secondary hyperoxaluria. Which medication should the nurse anticipate administering? a. Phenazopyridine (Pyridium) b. Propantheline (Pro-Banthine) c. Tolterodine (Detrol LA) d. Allopurinol (Zyloprim)

D Stones caused by secondary hyperoxaluria respond to allopurinol (Zyloprim). Phenazopyridine is given to clients with urinary tract infections. Propantheline is an anticholinergic. Tolterodine is an anticholinergic with smooth muscle relaxant properties.

17. A nurse cares for a client who is scheduled for the surgical creation of an ileal conduit. The client states, I am anxious about having an ileal conduit. What is it like to have this drainage tube? How should the nurse respond? a. I will ask the provider to prescribe you an antianxiety medication. b. Would you like to discuss the procedure with your doctor once more? c. I think it would be nice to not have to worry about finding a bathroom. d. Would you like to speak with someone who has an ileal conduit?

D The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his or her body. Discussing the procedure candidly with someone who has undergone the same procedure will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge. Medications for anxiety will not promote a positive self-image and a positive attitude, nor will discussing the procedure once more with the physician or hearing the nurses opinion.

14. A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for bladder cancer? a. A 25-year-old female with a history of sexually transmitted diseases b. A 42-year-old male who has worked in a lumber yard for 10 years c. A 55-year-old female who has had numerous episodes of bacterial cystitis d. An 86-year-old male with a 50pack-year cigarette smoking history

D The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.

The nurse is teaching the importance of a low purine diet to a client admitted with urolithiasis consisting of uric acid. Which statement by the client indicates that teaching was effective? A. "I am so relieved that I can continue eating my fried fish meals every week." B. "I will quit growing rhubarb in my garden since I'm not supposed to eat it anymore." C. "My wife will be happy to know that I can keep enjoying her liver and onions recipe." D. "I will no longer be able to have red wine with my dinner."

D. "I will no longer be able to have red wine with my dinner." Nutrition therapy depends on the type of stone formed. When stones consist of uric acid (urate), the client should decrease intake of purine sources such as organ meats, poultry, fish, gravies, red wines, and sardines. Reduction of urinary purine content may help prevent these stones from forming. Avoiding oxalate sources such as spinach, black tea, and rhubarb is appropriate when the stone consists of calcium oxalate.