elimination

Use of which the following classification of medications can cause increased urination? a) Cholinergic agents b) Analgesics c) Central nervous system depressants d) Stool softeners

Cholinergic agents Explanation: Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination.

Use of an indwelling urinary catheter leads to the loss of bladder tone. a) True b) False

True

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client? a) ?Are you taking a diuretic?? b) ?Are you taking any B-complex vitamins?? c) ?Are you taking levodopa (L-dopa)? d) ?Are you taking phenazopyridine (Pyridium)??

?Are you taking any B-complex vitamins?? Correct Explanation: Certain drugs can cause the urine to change color; and vitamin B-complexes can turn the urine green. Diuretics may cause the urine to turn pale yellow. Phenazopyridine may cause the urine to turn orange or orange-red, whereas Levodopa may cause the urine to turn brown or black. (less)

A nurse is assessing a client who is complaining of difficulty urinating. Which of the following would be a priority? a) Obtaining the bladder scanner to check the urine volume b) Determining any pain when palpating the lower abdomen c) Palpating the bladder above the symphysis pubis d) Asking the client when he/she had last urinated

Asking the client when he/she had last urinated Correct Explanation: The nurse, in assessing the bladder, 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.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which of the following measures should be included? a) Assist the client to a normal voiding position when possible. b) Encourage the client to wait to void at least 30 minutes when the urge is felt. c) Explain to the client that privacy is not important with urination. d) Place the client on a schedule to void every 4 hours during the daytime hours.

Assist the client to a normal voiding position when possible. Correct Explanation: 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.

Which of the following accurately describes a guideline when inserting an indwelling catheter? a) Use the largest appropriate-sized catheter. b) Maintain an open system whenever possible. c) Use clean technique when inserting a catheter. d) Avoid irrigation unless needed to relieve an obstruction.

Avoid irrigation unless needed to relieve an obstruction. Correct Explanation: Irrigation should be avoided unless there is an obstruction to prevent infection. A closed system should be maintained using sterile technique. The smallest appropriate-sized catheter should be used

Which of the following statements should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? a) Boys may walk by 1 year and should be continent by 3 years b) Incontinence after the age of 3 years is not normal c) Boys may take longer for daytime continence than girls d) Daytime continence is usually not achieved by boys until age 5

Boys may take longer for daytime continence than girls Correct Explanation: 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 woman complains of bladder urgency. It is most important to assess a) Weight b) Exercise c) Vitamin supplements d) Caffeine intake

Caffeine intake Correct Explanation: Alcohol and caffeine-containing fluids or food, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts

A home care nurse visits a client diagnosed with depression who informs the nurse that he has been prescribed amitriptyline. Which of the following would the nurse include when teaching the client about the effects of this mediation? a) Causes urine to turn blue-green b) Causes urinary retention c) Decreases glomerular filtrate rate d) Decreases sensation of bladder fullness

Causes urine to turn blue-green Correct Explanation: The nurse should inform the client that amitriptyline turns the urine blue-green. The risk of urinary retention is increased with medications that have anticholinergic effects. Tricyclic antidepressants and antihistamines are examples of such drugs. Narcotics can decrease the sensation of bladder fullness and the glomerular filtration rate.

When a client is diagnosed with a urinary tract infection, the nurse anticipates that the client's urine will be a) Transparent with an aromatic odor b) Greenish with a strong ammonia odor c) Cloudy with an offensive odor d) Light yellow with a faint ammonia odor

Cloudy with an offensive odor Correct Explanation: A strong, offensive odor is not normally present in urine that is free of infection.

The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted? a) The novice nurse asks the client when was the last time he voided before palpating the bladder. b) The novice nurse asks the client to urinate before palpating the bladder. c) The novice nurse observes the lower abdominal wall for any swelling. d) The novice nurse measures the height of the edge of the bladder above the symphysis pubis.

Correct response: The novice nurse asks the client to urinate before palpating the bladder. Explanation: The urinary bladder cannot be palpated when empty, so the client should not urinate before the nurse palpates or percusses it. During data collection, the client should be asked when the last time he voided was, before the bladder is palpated. The height of the edge of the bladder should be measured above the symphysis pubis. The lower abdominal wall during an urinary bladder assessment is observed for any swelling

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record? a) Inadequate elimination of urine b) Greater than normal urinary volume c) Absence of urine d) Difficult or uncomfortable voiding

Greater than normal urinary volume Correct Explanation: Polyuria means greater than normal urinary elimination. It may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects (e.g., coffee, tea), or taking certain medications actually can increase urination. Oliguria is inadequate elimination of urine. Anuria means the absence of urine. Dysuria is difficult or uncomfortable voiding.

A nurse assesses the urine of a patient who is using a bedpan and finds that it is a dark brown color. What medication might be causing this effect? a) Levodopa b) Diuretics c) Phenazopyridine d) Amitriptyline

Levodopa Correct Explanation: Levodopa and injectable iron compounds can cause brown or black urine. Phenazopyridine can cause orange or orange-red urine. Amitriptyline can cause green or blue-green urine, and diuretics can lighten the color of urine to pale yellow. (less)

A client has been NPO after midnight for surgery. It is 11:00 AM and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be a) Tea colored b) Pale yellow c) Colorless d) Dark amber

Dark amber Correct Explanation: 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 nurse assessing an elderly patient finds that the patient has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause? a) Decreased bladder muscle tone b) Diminished ability to concentrate urine c) Neurologic weakness d) Decreased bladder contractility

Decreased bladder contractility Correct Explanation: The nurse would suspect the client had decreased bladder contractility, which lead to the client having issues with urinary retention. Diminished ability to concentrate urine would be an issue with the kidney, not the urinary tract

A patient with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. The nurse reviews measures to follow to promote health and decrease the risk of contracting a UTI. Which measure is appropriate for the patient to follow? a) Take baths instead of showers. b) Wear satin or silk underwear that hugs the skin tightly. c) Wipe the perineal area from the rectal area to the urethra. d) Drink two glasses of water before and after sexual intercourse

Drink two glasses of water before and after sexual intercourse. Correct Explanation: Measures to decrease the risk for a UTI include drinking ten 8-ounce glasses of water daily, observing for signs and symptoms of a UTI, drying the perineal from the urethra toward the rectum, drinking two glasses of water before and after sexual intercourse, showering rather than bathing, wearing cotton underwear, avoiding tight constricting clothing, and drinking cranberry or blueberry juice daily

A nurse is caring for a patient with an external condom catheter. Which of the following is a guideline for applying and caring for this type of catheter? 读清楚选项！！ a) Remove the catheter every 8 hours, or more often in humid weather. b) Fasten the condom securely enough to prevent leakage without constricting the blood vessels. c) Wash the penis with antimicrobial soap and dry thoroughly. d) Keep the tip of the tubing 2 to 3 inches beyond the tip of the penis

Fasten the condom securely enough to prevent leakage without constricting the blood vessels. Explanation: Nursing care of a patient 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 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.

The nurse collects a urine sample from a client for urinalysis. Which of the following would the nurse document as a normal characteristic? a) Light yellow color b) Ammonia odor c) Presence of mucus shreds d) Cloudy appearance

Light yellow color Correct Explanation: Normal urine is light yellow in color. A cloudy appearance, the presence of mucus shreds, and an ammonia odor indicate abnormality in urine. The color of urine ranges from a light yellow, to a darker yellow, to a dark yellow-brown called amber. Urine is normally transparent. Freshly voided urine should appear clear, without sediment. Urine appears cloudy due to separation or settling of urinary constituents. Mucus shreds may be present in urinary samples taken from a catheter. The odor of freshly voided urine is typically described as aromatic. Collected urine that has been sitting unemptied for a long period may have a strong ammonia scent

A patient is suspected of having a disease process affecting the functional unit of the kidney. The nurse correctly recognizes which of the following stuctures is most likely involved? a) Nephron b) Glomerulus c) Bowman's capsule d) Loop of Henle

Nephron Correct Explanation: The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman's capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman's capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.

The nurse has entered a patient's room to empty the patient's urine collection bag at the end of a busy shift. The nurse realizes that the patient's urine output is 75 mL over the past 8 hours. The nurse would recognize that the patient is experiencing which of the following? a) Oliguria b) Nocturia c) Polyuria d) Anuria

Oliguria Correct Explanation: Oliguria is a significant decrease in urine production. Anuria is an absence or near-absence of urine output, while nocturia is nighttime awakening to void and polyuria is greatly increased urine production.

An older adult woman tells the nurse that she has trouble controlling her urine. She states, "The urine starts dripping even before I feel like I have to go." The nurse interprets this as which of the following? a) Urge incontinence b) Stress incontinence c) Functional incontinence d) Overflow incontinence

Overflow incontinence Explanation: The client is describing overflow incontinence, which occurs when the bladder muscle distends and urine is forced out. Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contraction. Stress incontinence is caused by weakening of the pelvic floor muscle or urethral hypermobility. Functional incontinence occurs when a physical or psychological impairment impedes continence despite a competent urinary system.

A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which of the following interventions should the nurse perform when providing continuous irrigation? a) Empty the balloon with a syringe. b) Prime the tubing with the solution. c) Clean around the urinary meatus. d) Place the sterile solution on the bed.

Prime the tubing with the solution. Correct Explanation: When providing continuous irrigation, the nurse must prime the tubing with the irrigation solution to ensure that no air enters the system. The nurse should hang the sterile irrigating solution from an IV pole, rather than place it on the bed, to allow it to flow freely. The nurse empties the balloon with a syringe and also cleans the urinary meatus when removing the catheter and not when irrigating the catheter.

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The presence of which of the following will support the potential diagnosis? a) Protein b) Calculi c) Casts d) Pus

Pus Correct Explanation: Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI.

A nurse is performing an intermittent closed catheter irrigation on a patient and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's response to this situation? a) Repeat the irrigation. b) Prepare to change the catheter. c) Notify the primary care provider. d) Wait 3 hours and repeat irrigation.

Repeat the irrigation. Correct Explanation: If the tubing was not clamped before introducing the irrigation solution, the nurse should repeat the irrigation. If the tubing is not clamped, the irrigation solution will drain into the urinary drainage bag and not enter the catheter.

Which type of incontinence is caused by pelvic floor muscle weakness? a) Urge b) Overflow c) Stress d) Functional

Stress Correct Explanation: Stress incontinence is caused by pelvic floor muscle weakness. Urge incontinence is the inability to suppress urination after sensing the need to do so; many physical and psychological issues can be related to this problem. Overflow incontinence is related to overdistention or overflow of the bladder. Causes of functional incontinence include environmental barriers, physical limitations, memory loss, and disorientation.

The nurse is preparing to catheterize a patient who is incontinent of urine following bladder surgery. What fact should the nurse keep in mind when performing catheterization? a) A normal bladder is as susceptible to infection as an injured one. b) The external opening to the urethra should always be sterilized. c) Pathogens introduced into the bladder remain in the bladder. d) The bladder normally is a sterile cavity.

The bladder normally is a sterile cavity. Correct Explanation: The bladder is normally a sterile cavity. It is not possible to sterilize a part of the human body, only disinfect it. Pathogens introduced into the bladder have the ability to enter other parts of the body, including the blood stream. An injured bladder is much more susceptible to infection than a normal bladder.

The nurse is providing teaching to a patient who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the patient? a) Restrict daily fluid intake. b) Empty the catheter bag every few days when it is full. c) The catheter can be connected to a smaller leg bag for ambulation. d) Clamp the catheter tubing daily for 2 hours and then release the clamp at night.

The catheter can be connected to a smaller leg bag for ambulation. Correct Explanation: Teaching points related to an indwelling urinary catheter include instructions on connecting the catheter to a smaller leg bag for ambulation, maintaining adequate fluid intake, keeping the catheter free of kinks (including avoiding clamping the catheter tubing), emptying the drainage bag at regular intervals, and avoiding a full drainage bag that may lead to reflux of urine.

You are inserting a urinary catheter into a 63-year-old male patient and encounter resistance. Which of the following is the most likely cause of the resistance? a) You failed to deflate the retention balloon after pretesting it for integrity. b) The diameter of the catheter is too large. c) The patient has an enlarged prostate. d) The patient has an occult abscess in the urethra.

The patient has an enlarged prostate. Explanation: Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization.

The nursing student who is learning skills during campus lab identifies which of the following statements about bedpans to be true? a) A regular bedpan is generally more comfortable for clients than a fracture bedpan. b) The rounded shelf of a regular bedpan should be placed under the client's buttocks. c) A fracture pan is preferred for urination and a regular bedpan is preferred for defecation. d) A fracture bedpan should used only for clients who have fractures of the femur or lower spine.

The rounded shelf of a regular bedpan should be placed under the client's buttocks. Correct Explanation: The only true statement is that the rounded shelf of the regular bedpan should be placed under the client's buttocks. Very thin and older adult clients may prefer the fracture bedpan. Both types of bedpans can be used for either urination or defecation. A fracture bedpan can be used for any client.

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action, by the UAP, is noted? a) UAP places the hand closest to the client palm up, under the lower back, and assists with lifting. b) UAP applies powder to the rim of the bedpan. c) UAP positions the bedpan so the client?s buttocks rest on the shallow end of the regular bedpan. d) UAP places a waterproof pad under the client?s buttocks before placing bedpan.

UAP positions the bedpan so the client?s buttocks rest on the shallow end of the regular bedpan. Explanation: It is important to place the bedpan in the proper position to prevent spills onto the bed, ensure client comfort, and prevent injury to the skin from a misplaced bedpan. Therefore, the UAP should position the bedpan so the client?s buttocks rest on the rounded shelf of the regular bedpan. Applying powder to the rim of the bedpan helps keep the bedpan from sticking to the client's skin and makes it easier to remove, unless it is contraindicated. The nurse uses less energy when placing the hand closest to the client palm up, under the lower back, and assisting with client lifting. A waterproof pad protects the bed from bedpan spillage.

The nurse measures a patient's residual urine by catheterization after the patient voids. What condition would this test verify? a) Urinary tract infection b) Urinary incontinence c) Urinary retention d) Urinary suppression

Urinary retention Correct Explanation: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Urinary incontinence is the inability for the client to control their urine. There are many different causes for urinary incontinence. Urinary tract infections are a leading cause of morbidity and health care expenditures in persons of all ages, accounting for up to 40% of infections reported by acute care hospitals. These infections can be of the upper or lower urinary system. Urinary retention is the inability to urinate. The causes of urinary retention are numerous.

A patient was admitted with prostate gland enlargement. The patient continues to demonstrate urinary frequency with only small amounts voided with each void and is restless. The patient is most likely experiencing Question 6 options: Urinary retention Functional incontinence Residual urine Dysuria

a

A woman informs the nurse that when she is experiencing stress it is difficult to void and wonders why this happens? The nurse explains a) "You require greater privacy to void." b) "Stress causes the muscles to become tense." c) "You might have a neurologic condition." d) "What medications are you taking?"

"Stress causes the muscles to become tense." Correct Explanation: A person's muscles may become so tense that relaxation of the perineal muscles does not occur, and voiding is inhibited

When documenting a common symptom of urinary alteration, the nurse would correctly document voiding a diminished urine output of 325 cc over 24 hours as Question 5 options: Oliguria Polyuria Urinary retention. Dribbling

A Correct. Oliguria is scanty or greatly diminished amount of urine in a given time. Output would be between 100 and 400 cc over 24 hours

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. Which of the following could cause this variation in color of the urine? a) Stasis b) Dehydration c) Infection d) Blood

Blood Correct Explanation: 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.

Your patient is an alert 40-year-old male, who is timid and reluctant to talk about his urinary retention. Which part of this plan of care could create stress for the patient and possibly increase his inability to urinate? Question 7 options: Assist patient in assuming his usual voiding position. Pull curtains around patient to provide privacy during voiding. Stay with the patient while he is voiding. Offer the urinal on a regular schedule.

C The patient will be embarrassed if the nurse remains with him as he attempts to urinate and is more likely to have difficulty voiding.

A nurse uses a portable bladder ultrasound device to assess bladder volume for a patient who is unable to void. Which of the following accurately states information needed to interpret the results? a) A postvoid residual (PVR) volume more than 50 mL indicates adequate bladder emptying. b) The device must be programmed for the gender of the patient by pushing the correct button on the device. c) The scan is contraindicated for a female who had a hysterectomy. d) A PVR of less than 150 mL is often recommended as the guideline for catheterization, because this has been associated with the development of urinary tract infections

Correct response: The device must be programmed for the gender of the patient by pushing the correct button on the device. Explanation: The device must be programmed for the gender of the patient by pushing the correct button on the device. If a female patient has had a hysterectomy, the male button is pushed. A postvoid residual (PVR) volume less than 50 mL indicates adequate bladder emptying. A PVR of greater than 150 mL is often recommended as the guideline for catheterization, because residual urine volumes of greater than 150 mL have been associated with the development of urinary tract infections

A client who visits a health care facility for a routine assessment complains to the nurse that he is unable to control his urinary elimination. This has resulted in him soiling his clothes and has lead to a lot of embarrassment. How should the nurse document the client's condition? a) Nocturia b) Dysuria c) Incontinence d) Albuminuria

Incontinence Correct Explanation: The nurse should document the client's condition as urinary incontinence. Incontinence is the inability to control either urinary or bowel elimination and is abnormal after a person is toilet-trained. Albuminuria is urine containing excessive protein. Dysuria is difficult or uncomfortable voiding.

that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which of the following would the nurse document as an abnormal finding? a) Reddened perineal skin b) Presence of smegma c) Absence of discharge d) Moist perineal skin

Reddened perineal skin Correct Explanation: 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.

A physician orders a long-term continuous drainage system to monitor a critically ill patient. What type of catheter would best suit this patient's needs? a) Indwelling urethral catheter b) Intermittent urethral catheter c) Suprapubic catheter d) External catheter

Suprapubic catheter Correct Explanation: Suprapubic catheters are recommended for long-term continuous drainage because they are associated with a decreased risk of contamination with organisms from fecal material, the elimination of damage to the urethra, a higher rate of patient satisfactions, and a lower risk of UTIs.

Health promotion activities that the nurse might include in patient teaching to assist a patient in achieving normal defecation would include Question 3 options: Frequent use cathartics and laxatives Lying flat to achieve continence on the bedpan Limiting strenuous exercise that would hinder bowel functioning Assure that the patient provides time to defecate when feels the urge to do so

dCorrect. Prompt response may help the patient reduce episodes of constipation

Choice Multiple question - Select all answer choices that apply. A nurse performing continuous bladder irrigation on a patient notes that hourly drainage is less than amount of irrigation being given. Which of the following interventions would be appropriate in this situation? Select all that apply. a) Palpate for bladder distention. 3选 b) Roll the patient onto his or her back c) Remove the catheter in place. d) Check to make sure that the tubing is not kinked. e) Lower the bag 3 to 6 inches and recheck the patient. f) If return flow remains decreased, notify the physician.

• Palpate for bladder distention. • Check to make sure that the tubing is not kinked. • If return flow remains decreased, notify the physician. Explanation: The nurse should palpate for bladder distention; if patient is lying supine, roll the patient onto his or her side to help increase the amount of drainage. The nurse should also check to make sure that the tubing is not kinked and if return flow remains decreased, notify the physician.

Choice Multiple question - Select all answer choices that apply. The nurse has an order to obtain a urine specimen from a client with an indwelling Foley catheter. Which of these supplies would the nurse need to gather? (Select all that apply.) a) Antiseptic swab b) 10-mL (milliliter) syringe c) Sterile specimen container d) Consent form e) Sterile gloves

• Sterile specimen container • Antiseptic swab • 10-mL (milliliter) syringe Correct Explanation: The nurse would need to gather a syringe, antiseptic swab, and sterile specimen container. The nurse would need clean, not sterile gloves, to perform the collection. The port of the tubing that connects to the catheter is where the specimen is collected from, and the nurse may need a clamp to allow a collection of urine within the tubing in case urine output is decreased.

Several of the patients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which of the following statements suggests that the patient requires further teaching? a) "I make sure to limit how much I drink so that I don't have accidents." b) "I know it's hard to get there, but I want to try to use the commode instead of wearing an adult diaper." c) "I've made a point of scheduling when I drink water instead of waiting until I'm thirsty." d) "At home, I take my water pill in the morning so that I don't have to use the bathroom as much during the night."

"I make sure to limit how much I drink so that I don't have accidents." Correct Explanation: Limiting fluid intake is not a healthy practice, and patients should be encouraged not to use fluid restriction as an incontinence management strategy. Promoting fluid intake is beneficial for most patients who do not possess a contraindication, and it is appropriate and useful to take diuretics in the morning to avoid nocturia. Even though it may involve work for both the patient and the nurse, patients who want to use a bathroom or commode rather than an adult brief should be encouraged to do so.

To promote drainage of a client's Foley catheter, which intervention would be most important for the nurse to implement? a) Securing the catheter to the client?s thigh or abdomen after placement b) Ensuring the balloon on the catheter is properly inflated with insertion c) Confirming the catheter tubing is not lying under the client d) Keeping the catheter drainage bag off the floor at all times

Confirming the catheter tubing is not lying under the client Correct Explanation: The measure that directly relates to proper drainage of the catheter is being sure that the catheter tubing is free and clear of any obstructions, such as being under the client. The drainage bag should also be lower than the client?s bladder. The drainage bag should not be on the floor to prevent infection. The nurse would secure the catheter after insertion to prevent pulling of the catheter, which can cause irritation. The nurse would also ensure the balloon on the catheter is properly inflated to prevent movement of the catheter, which can also cause irritation.

A common cause of lower urinary tract infection would be Question 2 options: Kinked or blocked urethral catherter Emotional anxiety Multiple childbirths High fluid intake

a

Choice Multiple question - Select all answer choices that apply. When planning care for a client with a Foley catheter, which actions should the nurse include? (Select all that apply.) a) Change the indwelling catheter regularly. b) Use powder or lotion in the perineal area. c) Record volume and character of the urine. d) Encourage fluid intake, unless contraindicated. e) Maintain a closed urinary catheter system.

• Maintain a closed urinary catheter system. • Encourage fluid intake, unless contraindicated. • Record volume and character of the urine. Correct Explanation: The client with a Foley catheter should maintain a closed drainage system to prevent introduction of pathogens into the system, and should have the urinary output monitored closely to determine adequate volume. The client can have natural irrigation of the catheter with an increased intake of fluid, if not contraindicated, which also reduces potential for infection. The character of the urine should also be monitored to determine any signs of urinary tract infection. The indwelling catheter should not be changed regularly but only as needed. Powder or lotion should not be used in the perineal area, but the area should be cleansed daily or after each bowel movement.

Choice Multiple question - Select all answer choices that apply. The nurse is assessing a patient's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? (Select all that apply.) a) The nurse presses and holds the END button until it beeps three times and then reads the volume measurement on the screen. b) The nurse adjusts the scanner head to center the bladder image on the crossbars. c) The nurse places a generous amount of ultrasound gel or gel pad midline on the patient's abdomen, about 1 to 1.5 inches above the symphysis pubis. d) The nurse gently palpates the patient's symphysis pubis. e) The nurse places the scanner head on the gel or gel pad, with the directional icon on the scanner head pointed away from the patient's head. f) The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx).

• The nurse gently palpates the patient's symphysis pubis. • The nurse places a generous amount of ultrasound gel or gel pad midline on the patient's abdomen, about 1 to 1.5 inches above the symphysis pubis. • The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). • The nurse adjusts the scanner head to center the bladder image on the crossbars. Explanation: To correctly use the ultrasound bladder scanner, the nurse would gently palpate the client's symphysis pubis. Palpation identifies the proper location and allows for correct placement of scanner head over the patient's bladder. The nurse would place a generous amount of ultrasound gel midline on the client's abdomen. The gel is necessary to conduct the ultrasound waves for an accurate reading. The nurse would aim the scanner head toward the bladder. Failure to point the scanner in this direction will give erroneous results. The nurse would adjust the scanner head to center the bladder image on the crossbars. This step is necessary to record the most accurate results.

A patient informs the nurse that he is concerned about dribbling and incontinence of small amounts of urine after the removal of his indwelling urinary catheter. The nurse is aware that the catheter was in place for three weeks prior to being removed. Which of the following is the nurse's best response to the patient? a) "Your symptoms are a normal part of the aging process." b) "It will take a little while for the bladder to re-establish control, and an accident is not unusual." c) "I will inform the physician, and we will likely need to perform a cystoscopy to look at your bladder." d) "Dribbling and incontinence often mean the bladder has lost tone, and the catheter will likely need to be reinserted."

"It will take a little while for the bladder to re-establish control, and an accident is not unusual." Correct Explanation: After the removal of an indwelling urinary catheter, it may take a little while for the bladder to re-establish voluntary control, and an accident is not unusual.

The nurse is assessing a female patient who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply? a) "You are experiencing transient incontinence. Have you been administered diuretics or IV fluids lately?" b) "You are experiencing reflex incontinence. Have you had a spinal cord injury in the past?" c) "You are experiencing stress incontinence. Do you know how to do Kegel exercises?" d) "You are experiencing total incontinence. Have you had any surgeries or trauma that may be causing this?"

"You are experiencing stress incontinence. Do you know how to do Kegel exercises?" Correct Explanation: Pelvic floor muscle training (PFMT) can improve voluntary control of urination and significantly reduce or eliminate problems with stress incontinence (involuntary loss of urine related to an increase in intra-abdominal pressure) by strengthening perineal and abdominal muscle tone (Huebner et al., 2011). PFMT, more commonly called Kegel exercises, targets the inner muscles that lie under and support the bladder. These muscles can be toned, strengthened, and actually made larger by a regular routine of tightening and relaxing. Transient incontinence appears suddenly and lasts for 6 months or less. It is usually caused by treatable factors, such as confusion secondary to acute illness, infection, and as a result of medical treatment, such as the use of diuretics or intravenous fluid administration. Stress incontinence (discussed earlier in the chapter) occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or other physical activities. Childbirth, menopause, obesity, or straining from chronic constipation can also result in urine loss. Total incontinence is a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation. Urination cannot be controlled due to an anatomic abnormality.

The nurse has an order to obtain a 24-hour urine from a client. Which of the following instructions would be accurate for collection of the specimen? a) ?Discard your first urine and begin the collection after that.? b) ?Begin the collection when you first urinate in the morning.? c) ?You will need to have a catheter inserted for this collection.? d) ?Start collecting the urine with the next time you urinate.?

?Discard your first urine and begin the collection after that.? Correct Explanation: 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 educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching? a) ?A woman using an intrauterine device for contraceptive reason is at risk for developing an UTI.? b) ?Due to the physiological changes with aging, the elderly are at risk for developing an UTI.? c) ?Having sexual relationships does not put a woman at risk for developing an UTI.? d) ?I will make sure to teach my clients with diabetes mellitus to control their glucose level to help prevent an UTI.?

?Having sexual relationships does not put a woman at risk for developing an UTI.? Correct Explanation: During sexual intercourse, bacteria from the perineal area may travel into the urethra and urinary bladder. The spermicide used with the diaphragm (IUD) decreases the vagina?s normally protective flora. The glucose in the urine acts an excellent medium for bacteria to proliferate in the client with diabetes mellitus. The elderly are predisposed to development of UTI due to the physiological changes associated with aging.

A client is diagnosed with frequent urinary tract infections. Which of the following would be an appropriate question for the nurse to ask the client? a) ?How often do you have a bowel movement?? b) ?How frequently do you urinate each day?? c) "Are you on any blood pressure medications?? d) ?Are you on any type of special diet at home??

?How frequently do you urinate each day?? Correct Explanation: The client with frequent urinary tract infections may have infrequent urination, which can lead to stagnation of urine in the bladder; this potentially leads to growth of bacteria. Taking blood pressure medication, being on a special diet, or having bowel movements do not increase the risk for urinary tract infections.

The nurse is caring for a hospitalized 3-year-old child. The mother expresses concern stating, ?My child was toilet-trained for three months. Since being here, she is no longer toilet-trained. I cannot understand this.? What appropriate response would the nurse provide to the mother? a) ?It is not unusual for children to regress when hospitalized; it should be short-lived.? b) ?It is unusual for a child this age to be toilet trained.? c) ?Since she is so young, you can re-train her again when she gets home.? d) ?Since she is wetting her underwear, she probably was not fully toilet-trained yet.

?It is not unusual for children to regress when hospitalized; it should be short-lived.? Correct Explanation: The nurse need to reassure the parent that regression of toilet skills that occurs during a hospitalization is to be expected and is usually short-lived. Voluntary sphincter control can occur as early as 18 months, if the child can hold urine for 2 hours, recognizes the feeling of bladder fullness, and communicate the need to void, the child can be toilet-trained. Telling the parent the child can be re-trained does not address her concerns.

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching? a) ?Having sexual relationships does not put a woman at risk for developing an UTI.? b) ?I will make sure to teach my clients with diabetes mellitus to control their glucose level to help prevent an UTI.? c) ?Due to the physiological changes with aging, the elderly are at risk for developing an UTI.? d) ?A woman using an intrauterine device for contraceptive reason is at risk for developing an UTI.?

?One signal of preparedness is when your child is dry for at least 2 hours.? Explanation: A child is typically 2-3 years old before beginning toilet training, although this does depend on the culture. The child signals readiness by staying dry for longer periods; usually at least 2 hours. The child may feel a sensation of bladder fullness, but is not necessarily able to express this. Boys may take longer to be ready for toilet training instead of girls. (less)

A client states that urinary incontinence has become a problem and asks the nurse how to help control or alleviate this problem. Which statement by the nurse would be accurate? a) ?You need to decrease your daily fluid intake to help with this.? b) ?It is best to have a Foley catheter inserted to prevent incontinence.? c) ?Coffee and diet sodas are not factors with being incontinent of urine.? d) ?Performing Kegel exercises can help with muscle strengthening.

?Performing Kegel exercises can help with muscle strengthening.? Correct Explanation: The client with urinary incontinence may benefit from performing Kegel exercises several times daily to help tone pelvic floor muscles. The client would want to avoid caffeine, alcohol, and artificial sweeteners, as these increase risk of incontinence. The daily recommended fluid intake would be 1500-2000 mL, to prevent dehydration; fluid intake may be limited at night to decrease nocturia. A Foley catheter would not be routinely placed for this, but would instead be a last resort for incontinence.

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) ?Try to urinate immediately after sexual intercourse.? b) ?Clean the perineal area from back to front when using the bathroom.? c) ?Fluid intake is not a factor with urinary tract infections.? d) ?Routine tub baths are fine as long as you are bathing appropriately.?

?Try to urinate immediately after sexual intercourse.? Correct Explanation: The female client who has repeated UTIs needs health promotion teaching to avoid re-occurrence of these. Urinating immediately after sexual intercourse and drinking an adequate amount of water (eight 8-10 ounce 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.

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client? a) ?Void a small amount, stop, and discard it.? b) ?Void into the specimen hat in the toilet bowl.? c) ?You will have a catheter put in to collect the urine.? d) ?Save all urine for the next 24 hours.?

?Void a small amount, stop, and discard it.? Correct Explanation: When collecting a midstream urine specimen, the client voids a small amount, stop, and discards it; the first small amount helps to flush away organisms near the urinary meatus. The midstream urine specimen is a sterile specimen so it is not collected in the hat in the toilet bowl. The client will not need to be catheterized. It is a one-time specimen, so urine will not be collected for 24 hours.

When caring for a patient who is unable to tolerate a large amount of enema fluid, which solution should the nurse anticipate that the physician will order? Question 12 options: Hypertonic fluid Normal saline Soapsuds Tap water

A A hypertonic enema solution uses only 120 to 180 mL of solution. Hypertonic solutions expend osmotic pressure that draws fluid out of the interstitial spaces: fluid pulled into the colon and rectum distend the bowel, causing an increase in peristalsis resulting in bowel evacuatio

During removal of a fecal impaction, which of the following could occur because of vagal stimulation? Question 8 options: Bradycardia Atelectasis Tachycardia Decrease bowel sounds in all four quadrants

A removal of a fecal impaction manually may result in stimulation of the vagal nerve and result in bradycardia.

A nurse is caring for an elderly client at his home. The client has had a condom catheter applied. Which of the following describes a condom catheter? a) A flexible sheath that is rolled around the penis b) A urine drainage tube that is left in place over a period of time c) A bag attached by adhesive backing to the skin around the genitals d) A urine drainage tube inserted but not left in place

A flexible sheath that is rolled around the penis Correct Explanation: A condom catheter is a flexible sheath that is rolled around the penis. A urinary bag (U-bag) is a bag attached by adhesive backing to the skin surrounding the genitals. A straight catheter is a urine drainage tube inserted but not left in place; a retention catheter is a urine drainage tube that is left in place over a period of time. (less)

A nurse collects a clean-catch specimen from a client at a health care facility. Which of the following statements describes a clean-catch urine sample? a) A sample of urine collected over a period of 24 hours b) A sample of urine collected in a sterile environment c) A sample of fresh urine collected in a clean container d) A sample of urine that is considered sterile

A sample of urine that is considered sterile Explanation: A clean-catch specimen is a sample of urine that is considered sterile. A clean-catch specimen is preferred to a randomly voided specimen. This method of collection is preferred when a urine specimen is needed during a client's menstrual cycle. A void specimen is a sample of fresh urine collected in a clean container. A catheter specimen is a sample of urine collected in a sterile environment using a catheter. A 24-hour specimen is a sample of urine collected over a 24-hour period.

When caring for a patient with an indwelling catheter the nurse knows that it is necessary to maintain the closed urinary drainage system. While caring for the patient the nurse would Question 4 options: Place all excess tubing off the bed to prevent the patient from lying on the tubing Be sure to plan to reinsert the catheter at intermittent intervals Maintain patency of the system and monitor urine flow Remove catheter to reduce the risk of urinary tract infection

C Correct. The nurse would correctly monitor the urine flow of a closed system for urine drainage and prevent urine reflux by keeping the drainage bag below the level of the bladder.

When differentiating among the types of urinary incontinence, the nurse understands that stress incontinence occurs: Question 11 options: With a urinary tract infection In response to emotional strain As a result of increased intra-abdominal pressure When a specific volume of urine is in the bladder

C When intra-abdominal pressure increases, the person with stress incontinence experiences urinary dribbling or an approximate loss of 50 mL of urine or less.

During his stay in the hospital, Mr. Wheeler has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in Mr. Wheeler's care? a) Indwelling catheter b) Condom catheter c) Intermittent catheterization at bedtime d) Adult incontinence briefs

Condom catheter Explanation: A condom catheter may be used in the care of male patients who lack voluntary control of urination. This is preferable to invasive catheterization, which presents an infection risk, and incontinence briefs, which may promote skin breakdown.

The nurse is performing data collection on an elderly client brought to the clinic by his daughter. Which finding collected would indicate to the nurse that the client may have a urinary tract infection (UTI)? a) Frequency b) Confusion c) Gender d) Nocturia

Confusion Correct Explanation: The elderly client, with an UTI, may be asymptomatic except for mental confusion. In aging, the kidneys? ability to concentrate urine may result in nocturia. The urinary bladder may have reduced capacity due to decreased muscle tone that results in urinary frequency in the elderly. Women are more vulnerable to UTIs because the urethra is shorter and in closer proximity to the vagina and rectum

The nurse is performing data collection on an elderly client brought to the clinic by his daughter. Which finding collected would indicate to the nurse that the client may have a urinary tract infection (UTI)? a) Nocturia b) Gender c) Frequency d) Confusion

Confusion Explanation: The elderly client, with an UTI, may be asymptomatic except for mental confusion. In aging, the kidneys? ability to concentrate urine may result in nocturia. The urinary bladder may have reduced capacity due to decreased muscle tone that results in urinary frequency in the elderly. Women are more vulnerable to UTIs because the urethra is shorter and in closer proximity to the vagina and rectum.

Which information listed below most directly relates with an elderly client with urinary retention? a) Elderly clients who have limited support can feel powerless. b) Elderly clients may have a decrease in contraction of the bladder. c) Elderly clients have a decreased ability to concentrate urine. d) Elderly clients can have a decrease in bladder muscle tone.

Correct response: Elderly clients may have a decrease in contraction of the bladder. Explanation: Elderly clients have a decrease in bladder contraction, which can lead to decreased urination or urinary retention. If there is a decrease in bladder muscle tone, this may lead to frequent urination instead. Elderly clients can have a decreased ability to concentrate urine, which causes nocturia (urination during the night). Elderly clients also can feel powerless, which can cause incontinence.

The physician orders an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position? a) Sims position b) Semi-Fowler position c) Dorsal recumbent position d) Supine position

Correct response: Sims position Explanation: The Sims, or side-lying, position is especially used for clients who have limited hip mobility because it permits excellent visualization of the urinary meatus. Usually, female clients are placed in a dorsal recumbent position for catheterization, and male clients are put in a supine or semi-Fowler's position.

The nurse mentor is observing a novice nurse prepare to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene, if which action by the novice nurse is noted? a) The novice placed a trash receptacle within easy reach. b) The novice assisted the client to a dorsal recumbent position with knees flexed, feet about 2 feet apart. c) The novice asked the client to take a deep breath when resistance was met during insertion of the catheter. d) The novice selected an 18 French Foley catheter to insert.

Correct response: The novice selected an 18 French Foley catheter to insert. Explanation: A 14F to 16F size catheter should be used when catheterizing an adult client. Size 18F can distend the urethra and cause more discomfort to the client during the procedure, as well as increase erosion of the bladder. If resistance is met, having the client take a deep breath helps relaxes the external sphincter. Placing a trash receptacle within easy reach trash allows for prompt disposal of used supplies and reduces the risk of contaminating the sterile field. The dorsal recumbent position allows adequate visualization of the urinary meatus.

Choice Multiple question - Select all answer choices that apply. The nurse is caring for a client with a Foley catheter in place who has a prescription for a sterile urine specimen for culture and sensitivity. The nurse implements which techniques to obtain the prescribed urine specimen? (Select all that apply.) 2 选 a) The nurse clamps the tube below the access port for 40 minutes to allow urine to accumulate. b) The nurse uses a syringe to withdraw urine from the port. c) The nurse disconnects the catheter and allows the urine to drip into the specimen container. d) The nurse dons clean gloves and cleanses the port with aseptic solution. e) The nurse allows the urine to flow from the collection bag into the specimen container.

Correct response: • The nurse uses a syringe to withdraw urine from the port. • The nurse dons clean gloves and cleanses the port with aseptic solution. Explanation: When collecting a sterile urine specimen from a Foley catheter, the nurse wears clean gloves, cleans the port with an aseptic solution, and withdraws the specimen from the port with a syringe. The specimen should not be taken from the collecting bag because it may not be fresh and could result in an inaccurate analysis. The catheter should not be disconnected in order to prevent bacteria from entering the urinary system. If urine is not present in the tube, the tube may be clamped, but not to exceed 30 minutes

The nurse is inserting a urinary catheter into a female patient and has begun to inflate the balloon, an action that has caused the patient to wince and cry out in pain. Consequently, the nurse should do which of the following? a) Wait for 30 seconds, help the patient to relax, and reattempt inflation. b) Stop, deflate the balloon, withdraw the catheter 2 to 4 cm, and slowly reinflate. c) Deflate the balloon, withdraw the catheter, and use a smaller sized catheter. d) Deflate the balloon, insert the catheter further, and slowly attempt reinflation

Deflate the balloon, insert the catheter further, and slowly attempt reinflation. Correct Explanation: If the patient complains of pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the patient's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 1/2 to 1 (1.22.4 cm), and slowly attempt to inflate the balloon again. Reattempting inflation in the same location or after withdrawing slightly could cause trauma to the patient's urethra. It is not necessary to utilize a smaller gauge catheter.

The nurse is caring for a client with urinary incontinence who has a prescription for a postvoid residual (PVR) collection. 45 mL of amber urine is returned via PVR. Which appropriate action would the nurse take with this data collection? a) Encourage the client to drink more fluids. b) Perform a bladder scan. c) Document the finding. d) Wait 30 minutes and re-catheterize the client.

Document the finding. Explanation: A PVR of less than 50 mL indicates the bladder is adequately emptying, so the nurse should document the findings. Since this normal there is no need to encourage more fluids, re-catheterize the client, or perform a bladder scan.

A client at a health care facility complains to the nurse that when traveling, he is unable to retain urine until he locates a toilet. How should the nurse document this incontinence in the client? a) Urge b) Functional c) Total d) Stress

Functional Correct Explanation: The nurse should document the client's condition as functional incontinence when the client is unable to retain urine for some time after getting an urge to void. Stress incontinence can result in the loss of small amounts of urine when intraabdominal pressure rises. Urge incontinence is the need to void perceived frequently with a short-lived ability to sustain control of flow. Total incontinence is the loss of urine without any identifiable pattern.

The nurse is caring for a client with a history of renal insufficiency and Type II diabetes mellitus. 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) Gentamicin (Garamycin) 70 mg intramuscular (IM) every 8 hours c) Blueberry juice 10 ounces by mouth (PO) daily d) Encourage fluids intake - 2 to 3 liters per day

Gentamicin (Garamycin) 70 mg intramuscular (IM) every 8 hours Explanation: Garamycin 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 mellitus, urine 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.

Which of the following is an accurate guideline to follow if there is not an immediate flow of urine after a catheter has been inserted? a) Lightly apply pressure on the patient's bladder until a flow of urine is established. b) Lower the head of the patient's bed to increase pressure in the bladder area. c) Pull out the catheter slightly, because a drainage hole may be resting against the bladder wall. d) Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles.

Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles. Explanation: A deep breath helps to relax the perineal and abdominal muscles. The nurse should rotate the catheter slightly, because a drainage hole may be resting against the bladder wall, and raise the head of the patient's bed to increase pressure in the bladder

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? not 多选题，看清楚! a) Explaining to the client that the procedure will be painful b) Inserting a Foley catheter the morning of the procedure c) Having the client sign a consent form for the procedure d) Maintaining the client without liquids before the procedure

Having the client sign a consent form for the procedure Correct Explanation: The client would sign a consent form for the procedure since it is invasive. This would be completed after the procedural health care provider had explained the purpose, risks, and benefits of the procedure. The client would not be maintained NPO (nothing by mouth) or 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

A male patient is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this patient? a) Impaired Skin Integrity related to urinary bladder infection and dehydration b) Impaired Skin Integrity related to functional incontinence c) Risk for Urinary Tract Infection related to dehydration d) Urinary Incontinence related to urinary tract infection

Impaired Skin Integrity related to urinary bladder infection and dehydration Correct Explanation: Impaired Skin Integrity related to urinary bladder infection and dehydration would be the appropriate nursing diagnosis. The nursing concern is his excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary Tract Infection is not a nursing diagnosis, rather a medical diagnosis. The impaired skin integrity is not related to functional incontinence. Urinary Incontinence is not a nursing diagnosis, rather a medical diagnosis.

The nurse is caring for a male patient who has a urinary obstruction and is not a candidate for surgery. What intervention would the nurse expect the health care provider to perform? a) Insertion of a urologic stent b) Insertion of a straight catheter c) Insertion of a suprapubic catheter d) Insertion of an indwelling urethral catheter

Insertion of a urologic stent Correct Explanation: The nurse would expect the health care provider would insert a urologic stent for this male client. Urologic stents relieve urinary obstructions and provide a path for the flow of urine. The other options are not appropriate for the clien

A nurse drains the bladder of a patient by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? a) Retention catheter b) Intermittent urethral catheter c) Indwelling urethral catheter d) Foley catheter

Intermittent urethral catheter Correct Explanation: 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 inflated to ensure that the catheter remains in the bladder once it is inserted.

You are attempting to insert a urinary catheter into a female patient's bladder and realize the catheter has been inserted into the vagina. Which of the following actions is most appropriate? a) Remove the catheter from the vagina and attempt to insert it into the bladder. b) Immediately remove the catheter from the vagina, contact the primary care provider and anticipate an order for prophylactic antibiotics. c) Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. d) Ask the patient to bear down until the catheter is expelled.

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Correct Explanation: Start the procedure over and attempt to place the new catheter directly above misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Never remove a catheter from the vagina and insert it in the urethra as this action can cause cross-contamination

You are attempting to insert a urinary catheter into a female patient's bladder and realize the catheter has been inserted into the vagina. Which of the following actions is most appropriate? a) Remove the catheter from the vagina and attempt to insert it into the bladder. b) Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. c) Ask the patient to bear down until the catheter is expelled. d) Immediately remove the catheter from the vagina, contact the primary care provider and anticipate an order for prophylactic antibiotics.

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Correct Explanation: Start the procedure over and attempt to place the new catheter directly above misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Never remove a catheter from the vagina and insert it in the urethra as this action can cause cross-contamination

A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? a) Need to void perceived frequently, with short-lived ability to sustain control of flow b) Loss of urine control because of inaccessibility of a toilet c) Loss of urine without any identifiable pattern or warning d) Loss of small amount of urine when intraabdominal pressure rises

Loss of urine without any identifiable pattern or warning Correct Explanation: The nurse could describe the client's condition as the loss of urine without any identifiable pattern or warning. Stress incontinence can be described as loss of a small amount of urine when intraabdominal pressure rises; whereas, urge incontinence can be described as the need to void perceived frequently with a short-lived ability to sustain control of flow. Functional urinary incontinence can be described as the loss of control over urination because of the inaccessibility of a toilet. (less)

Because of the older adult's inability to concentrate urine as a physiologic change, the nurse should assess the client for which condition? a) Nocturia b) Urinary stasis c) Incontinence d) Urinary retention

Nocturia Correct Explanation: The older adult has many physiologic changes that can relate to urination, and one of these is the inability of the kidneys to concentrate urine. This can lead to nocturia, or urination during the night. With clients who have an intact urinary tract, the kidneys concentrate urine during the night so that a person does not have to get up frequently to urinate. Incontinence can be caused by many factors for an elderly person including a decrease in bladder tone or a feeling of powerlessness. Urinary stasis or retention can be caused by a decrease in the bladder?s contractability.

Which of the following statements should be included in the nurse's teaching plan for older adults regarding urinary elimination? a) Most older adults experience an increased blood flow to the kidneys b) Nocturia and urinary retention is more common in older adults c) Kidney function progressively increases as the body ages d) The kidneys become more effective in filtration with age

Nocturia and urinary retention is more common in older adults Correct Explanation: Nocturia and urinary retention are common in older adults.

Which of the following is a recommended guideline when catheterizing the female urinary bladder? a) Lubricate 2 to 3 inches of the catheter tip before insertion. b) Using the dominant hand, hold the catheter by the tip and insert slowly into the urethra. c) Advance the catheter until there is a return of urine (approximately 4 to 5 inches) d) Once urine drains, advance the catheter another 2 to 3 inches.

Once urine drains, advance the catheter another 2 to 3 inches. Explanation: The nurse should lubricate 1 to 2 inches of the catheter tip and, using dominant hand, hold the catheter 2 to 3 inches from the tip and insert slowly into the urethra. The nurses should then advance the catheter until there is a return of urine (approximately 2 to 3 inches [4.8 to 7.2 cm]) and, once urine drains, advance catheter another 2 to 3 inches (4.8 to 7.2 cm).

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. Which of the following describes a urinary diversion? a) Inability to control either urinary or bowel elimination b) Use of a catheter to collect urine in a sterile environment c) Hygiene measures used to keep meatus and adjacent area of the catheter clean. d) One or both of the ureters are surgically implanted elsewhere

One or both of the ureters are surgically implanted elsewhere Correct Explanation: 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. (less)

A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which of the following interventions should the nurse perform when providing continuous irrigation? a) Purge air from the tubing b) Place the sterile solution on the bed c) Empty the balloon with a syringe d) Clean the urinary meatus

Purge air from the tubing Explanation: When providing continuous irrigation, the nurse must purge the air from the tubing to ensure that no air enters the system. The nurse should hang the sterile irrigating solution from an IV pole, rather than place it on the bed, to allow it to flow freely. The nurse empties the balloon with a syringe and also cleans the urinary meatus when removing the catheter and not when irrigating the catheter.

A laboratory test of a client's urine indicates the presence of pus in the urine. Which of the following terms is used to describe this type of urine? a) Hematuria b) Ketonuria c) Glycosuria d) Pyuria

Pyuria Correct Explanation: The term pyuria refers to the presence of pus in the urine. Hematuria is the presence of blood in the urine, glycosuria is the presence of glucose in the urine, and ketonuria indicates that the urine contains ketones. (less)

A nurse is caring for a client who has a 4-month-old infant. 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) Functional incontinence b) Urge incontinence c) Stress incontinence d) Reflex incontinence

Stress incontinence Correct Explanation: The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to childbirth. The nurse should not document the condition as reflex incontinence, urge incontinence, or functional incontinence. 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.

The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard? a) The bedtime voiding b) The first voiding of the day c) The voiding collected at 4 p.m. d) The sample collected immediately after lunch

The first voiding of the day Explanation: The nurse would discard the first void of the day. The bladder has collected urine that has been produced by the kidneys overnight. The first voided urine of the day is usually more concentrated than other urine excreted during the day. Because the first urine of the day is not fresh, but rather an accumulation of a number of hours of kidney output, this urine may or may not be used as a specimen for certain tests. The other options would be appropriate to use for urine tests

The nurse is choosing a collection device to collect urine from a nonambulatory male patient? What would be the nurse's best choice? a) Specimen hat b) Bedpan c) Large urine collection bag d) Urinal

Urinal Correct Explanation: A urinal is the best choice to collect urine from a nonambulatory male client. A specimen hat is for a commode. A bedpan is not the best choice for a male client. A large urine collection bag would be used with an indwelling catheter.

The nurse is reviewing the chart of an elderly client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed? 可能会考到！ a) Urine culture & sensitivity - 100,000/mL b) Blood urea nitrogen (BUN) -1 7 mg c) Hemoglobin - 40% d) Magnesium - 2.5 mEq/L

Urine culture & sensitivity - 100,000/mL Correct Explanation: 100,000 organisms per milliliter in an urine culture and sensitivity specimen is positive of a urinary tract infection. BUN, hemoglobin, and magnesium are all within the normal ranges.

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly? a) Using dominant hand, hold the catheter 12 inches from the tip and insert slowly into the urethra. b) Assist the patient to a prone position with knees flexed, feet about 2 feet apart, with legs abducted. c) Clean the perineal area with a gauze pad and alcohol using a different corner of the gauze with each stroke. d) Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe

Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe. Correct Explanation: The nurse would use the dominant hand to inflate the catheter balloon, and inject the entire volume of sterile water supplied in the prefilled syringe. The nurse would not hold the catheter 12 inches from the tip. This would result in the nurse having little control over the tip of the catheter and the catheter could easily become contaminated. The nurse would not cleanse the perineal area with a gauze pad and alcohol. Iodine swabs are used to clean the perineal area prior to catheter insertion. The nurse would assist the client into the supine position, not the prone position for the procedure. (less)

A nurse is preparing to measure a client's urine output. Which of the following interventions would be of highest priority? a) Measuring the urine container at eye level b) Noting the color and clarity of the urine c) Wearing gloves when handling the urine d) Using an appropriate measuring container

Wearing gloves when handling the urine Correct Explanation: All of these interventions would be important to ensure safety in handling the client's urine and obtaining an accurate output. However, safety with handling body fluids would be a priority for the nurse to decrease risk of exposure to pathogens or blood that may be in the client?s urine.

A caregiver of an 80-year-old patient tells the nurse that her mother frequently experiences nocturia and is sometimes incontinent. Following instructions about strategies to resolve the elimination problems, the nurse determines that the caregiver need further instructions when the caregiver says: Question 9 options: "I should be sure that my mother drink 2500 mL by 6:00 in the evening." "I need to discourage my mother from drinking a cup of coffee at supper." "My mother needs her walker at the bedside and a night light on in the bathroom to keep her safe." "Have Mom take her diuretic medication in the morning so she urinates during the day."

a Consuming 2500mL of fluid a day is close to what is recommended for adults. It would be best if the patient consumed these fluids early in the day. Otherwise, she will need to urinate frequently during the night

When planning for the elimination needs of a patient, the nurse understands that: Question 10 options: Peristalsis increases after ingestion of food Emotional stress initially decreases peristalsis Enema solutions should be administered at room temperature Intrathoracic pressure decreases when straining during defecation

a Food or fluid that enters and fills the stomach or the duodenum stimulates peristalsis

Which of the following statements about the use of a urinal is true? a) If nocturnal incontinence is anticipated, a urinal can be placed between the legs while the patient is asleep. b) Both male and female patients commonly void into a urinal in the bathroom to facilitate measurement of urinary output. c) Unless contraindicated, nurses should encourage patients to stand to use a urinal. d) Urinals must be replaced every 24 hours to reduce the risk of infection

c

A patient is having fewer than normal bowel movements with the difficult passage of hard, dry feces. The nurse would document this as Question 1 options: Impaction. Flatulance Hemorroids Constipation

d

Choice Multiple question - Select all answer choices that apply. The nurse is providing instructions to a client with kidney stones on measures to help prevent urinary tract infections (UTIs). Which statement made by the client, would indicate to the nurse that further teaching is necessary? (Select all that apply.) a) ?I will start wearing underwear with a cotton crotch.? b) ?I will notify my health care provider if my urine starts smelling again.? c) ?I will bathe in the bath tub rather than take a shower.? d) ?I will drink about ten 8-ounce glasses of water a day.? e) ?I will drink 10 ounces of cranberry juice every day.?

• ?I will drink 10 ounces of cranberry juice every day.? • ?I will bathe in the bath tub rather than take a shower.? Explanation: Even though cranberry juice is encouraged to prevent bacteria from adhering to the urinary bladder wall, it is not recommended for the client with kidney stones. The client should take showers instead of bathing in the bathtub to prevent UTIs. Drinking 8 to 10, 8-oz glasses of water daily, notifying the health care provider of any signs of infection, such as foul urine odor, and wearing underwear with a cotton crotch are measures to prevent UTIs.

Choice Multiple question - Select all answer choices that apply. Which of the following situations warrant urinary catheterization? Select all that apply. a) A patient has developed a urinary tract infection. b) A patient is in septic shock and highly unstable. c) A patient is unable to mobilize to the bathroom following abdominal surgery. d) A patient with an enlarged prostate is unable to void. e) A sterile urine specimen is needed from an acutely confused patient.

• A patient is in septic shock and highly unstable. • A sterile urine specimen is needed from an acutely confused patient. • A patient with an enlarged prostate is unable to void. Explanation: Reasons for urinary catheterization include monitoring acutely ill patients, obtaining sterile urine specimens from patients who cannot otherwise provide them and relieving urinary retention. The presence of a urinary tract infection does not necessarily indicate a need for catheterization and a patient who is immobile should be introduced to the use of a bedpan or commode.

Choice Multiple question - Select all answer choices that apply. A nurse is caring for an elderly patient who is incontinent. Which of the following effects of aging might contribute to urinary alterations? Select all that apply. a) Decreased bladder contractility may lead to urine retention and stasis. b) Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. c) Neuromuscular problems may interfere with voluntary control of urination. d) Altered thought processes may cause urinary frequency. e) Diminished ability of kidneys to concentrate urine may result in nocturia. f) Increased bladder motility decreases the incidence of urinary tract infections.

• Diminished ability of kidneys to concentrate urine may result in nocturia. • Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. • Decreased bladder contractility may lead to urine retention and stasis. • Neuromuscular problems may interfere with voluntary control of urination. Explanation: The effects of aging include diminished ability of kidneys to concentrate urine that may result in nocturia, decreased bladder muscle tone may reduce the capacity of the bladder to hold urine resulting in increased frequency of urination, decreased bladder contractility may lead to urine retention and stasis with increased risk of urinary tract infection, neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control of urination.

Choice Multiple question - Select all answer choices that apply. A nurse is caring for an elderly client who has been prescribed a condom catheter. What potential problems related to the use of condom catheter should the nurse monitor in the client? Select all that apply. a) Excoriation of the skin in the glans area b) Frequent urinary tract infection c) Frequent leakage of urinary output d) Inability to control urinary elimination e) Restricted blood flow to the glans tissue

• Excoriation of the skin in the glans area • Restricted blood flow to the glans tissue Correct Explanation: A potential problem that can occur with the use of condom catheters is the restriction of blood flow to the skin and tissues of the penis if the sheath is applied too tightly. Another potential problem is the tendency of moisture to accumulate beneath the sheath leading to skin breakdown or excoriation, especially the skin around the glans. A retention catheter, not a condom catheter, could lead to urinary tract infection. Use of a condom catheter does not lead to the inability to control urinary elimination. Care must be taken to fasten the condom securely enough to prevent leakage. (less)

Choice Multiple question - Select all answer choices that apply. The nurse is changing a stoma appliance on an ileal conduit. Which of the following nursing actions are recommended procedure? (Select all that apply.) a) Gently remove the appliance, starting at the top and keeping the abdominal skin taut. b) Remove appliance faceplate by pulling appliance from skin rather than pushing. c) Clean skin around stoma with alcohol on a gauze pad. d) Make sure skin around stoma is thoroughly dry by patting it dry. e) Apply faceplate by using firm, even pressure for approximately 60 seconds. f) Apply a silicone-based adhesive remover by spraying or wiping as needed.

• Gently remove the appliance, starting at the top and keeping the abdominal skin taut. • Apply a silicone-based adhesive remover by spraying or wiping as needed. • Make sure skin around stoma is thoroughly dry by patting it dry. Explanation: The nurse would gently remove the appliance, starting at the top and keeping the abdominal skin taut. This method would prevent excessive damage to skin and tissue of the client. The nurse would apply a silicone-based adhesive remover by spraying or wiping as needed. The adhesive remover helps to prevent skin and tissue damage. The nurse would make sure skin around the stoma is thoroughly dry by patting it dry. Moist skin does not hold adhesives well, possibly causing skin and tissue damage. The nurse would not remove the appliance faceplate by pulling the appliance from the skin rather than pushing. The nurse would not clean the skin around the stoma with alcohol. Alcohol is drying to the skin, possibly causing skin or tissue damage. The nurse would not hold the faceplate firmly in place for 60 seconds when placing it. Pressure for 30 seconds is sufficient.

Choice Multiple question - Select all answer choices that apply. The nurse is preparing a patient for an intravenous pyelogram. Which nursing actions are performed correctly? (Select all that apply.) 选4个 a) Tell the patient not to void before the test. b) Give a laxative the evening before the examination. c) Withhold or limit foods before testing. d) Obtain patient's allergy history. e) Restrict fluids and foods immediately after the examination. f) Give an enema the day of the examination.

• Give a laxative the evening before the examination. • Obtain patient's allergy history. • Withhold or limit foods before testing. • Give an enema the day of the examination. Correct Explanation: The nurse would expect to withhold or limit foods before testing, give an enema the day of the examination, obtain the client's allergy history, and give a laxative the evening before the examination. The nurse would have the client void before the test. The nurse would not restrict fluids and foods immediately after the examination.

Choice Multiple question - Select all answer choices that apply. A nurse is performing a physical assessment of a patient's urinary system. Which nursing actions are appropriate during this assessment? (Select all that apply.) a) The nurse places male patients in the dorsal recumbent position for good visualization of the meatus. b) The nurse inspects the urethral orifice for any signs of inflammation, discharge, or foul odor. c) The nurse measures the height of the edge of the bladder below the symphysis pubis. d) If using a bedside scanner, the nurse places the patient in a supine position. e) The nurse retracts the foreskin of an uncircumcised male patient to visualize the meatus. f) The nurse assess the patient's urine for color, odor, clarity, and the presence of any sediment.

• If using a bedside scanner, the nurse places the patient in a supine position. • The nurse inspects the urethral orifice for any signs of inflammation, discharge, or foul odor. • The nurse retracts the foreskin of an uncircumcised male patient to visualize the meatus. • The nurse assess the patient's urine for color, odor, clarity, and the presence of any sediment. Explanation: The nurse would place the client in the supine position if using a bedside scanner. This position is the only position that the nurse can correctly use the bedside scanner on the client. The nurse would inspect the urethral orifice for any signs of inflammation, discharge, foul odor. These symptoms could be a sign of a possible infection or other issue. The nurse would retract the foreskin of an uncircumcised male client to visualize the meatus. The nurse would assess the client's urine for color, odor, clarity, and the presence of any sediment. This characteristics could indicate a possible infection or other concern.

Choice Multiple question - Select all answer choices that apply. The nurse is catheterizing a male urinary bladder, and urine leaks out of the meatus around the catheter. What actions would the nurse perform next? (Select all that apply.) a) Increase the size of the indwelling catheter. b) Make sure the smallest sized catheter with a 10-mL balloon is used. c) Ensure that the correct amount of solution was used to inflate the balloon. d) Consider an evaluation for urinary tract infection. e) If under fill is suspected, attempt to push the catheter further into the bladder. f) Assess the patient for diarrhea.

• Make sure the smallest sized catheter with a 10-mL balloon is used. • Consider an evaluation for urinary tract infection. • Ensure that the correct amount of solution was used to inflate the balloon. Explanation: The nurse would make sure the smallest sized catheter with a 10-mL balloon is used for the procedure. Large catheters cause bladder and urethral irritation and trauma. Large, balloon-fill volumes occupy more space inside the bladder and put added weight on the base of the bladder. Irritation of the bladder wall and detrusor muscle can cause leakage. If leakage persists, consider an evaluation for urinary tract infection. Ensure that the correct amount of solution was used to inflate the balloon. Underfilling the balloon can cause the catheter to dislodge into the urethra. The nurse would not increase the size of the indwelling catheter. The nurse would not have a need to assess the client for diarrhea. The nurse would not attempt to push the catheter further into the bladder if under fill is suspected. This could cause trauma to the urethra or bladder of the client.

Choice Multiple question - Select all answer choices that apply. A nurse is collecting a urine specimen for urinalysis. What factors should the nurse consider when performing this procedure? (Select all that apply.) a) If a woman is menstruating, a urine specimen cannot be obtained for urinalysis. b) Urine should be left standing at room temperature for a 24-hour period before being sent to the laboratory. c) Sterile urine specimens may be obtained by catheterizing the patient's bladder. d) A clean-catch specimen of urine may be collected in midstream. e) A sterile urine specimen is required for a routine urinalysis. f) Strict aseptic technique must be used when collecting and handling urine specimens.

• Sterile urine specimens may be obtained by catheterizing the patient's bladder. • Strict aseptic technique must be used when collecting and handling urine specimens. • A clean-catch specimen of urine may be collected in midstream. Explanation: The nurse would use realize that a sterile urine specimen must be obtained by catheterizing the client's bladder. The nurse would use strict aseptic technique when collecting and handling urine specimens. The nurse would realize that a clean-catch specimen of urine would be collected midstream. The nurse would realize that a sterile specimen is not required for a routine urinalysis. The nurse would realize that a menstruating woman can give a specimen for urinalysis but this fact should be documented on the lab slip. The nurse would realize that urine cannot be left at room temperature for a 24-hour period before being sent to the laboratory.