Taylor's PrepU (Fundamentals) Ch. 38: Urinary Elimination

A client has been NPO (nothing by mouth) after midnight for surgery and the client has received no IV fluids. It is now 1300 and the nurse has asked the client to attempt to void before being transferred to the surgical suite. The nurse should expect the client's urine to be what color? Pale yellow Colorless Dark amber Tea colored

Dark amber 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

The health care provider has ordered a 24-hour urine specimen collection for a client. Which nursing action is appropriate? Select all that apply. Have client label own urine collection. Teach client to void only one time per hour. Discard first urine just before starting the test, then collect urine thereafter. Place urine in staff refrigerator. Ask client to void for the last time at exactly the 24-hour mark.

Discard first urine just before starting the test, then collect urine thereafter. Ask client to void for the last time at exactly the 24-hour mark. Explanation: The client will be instructed to void a first urine to be discarded, then all subsequent urination will be collected until the 24-hour mark when the client will be asked to urinate one last time. The nurse will label the container. Urine collected should be stored in a specimen-dedicated refrigerator, not a staff refrigerator.

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? Urge Stress Overflow Functional

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

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, dark amber strongly aromatic, amber

cloudy, foul odor Explanation: The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine. Urine is normally light yellow and clear. Dark amber urine that is strongly aromatic could indicate dehydration, but would not create the symptoms noted.

The nurse is caring for a male client who has a urinary obstruction and is not a candidate for surgery. Which intervention will the nurse prepare the client for? Insertion of an indwelling urethral catheter Insertion of a suprapubic catheter Insertion of a straight catheter Insertion of a urologic stent

Insertion of a urologic stent 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 this client.

A nurse prepares a client with a recently created ileal conduit to be discharged from the hospital. Which is an expected assessment finding? Stoma is pale to light pink in color. Stoma is fully stable. Stoma is flush with the abdominal surface. Mucus in the urine is a normal finding.

Mucus in the urine is a normal finding. Explanation: The isolated segment of small intestine continues to produce mucus (seen in the urine), as part of its normal functioning. The stoma should be dark pink to red and moist. The size of the stoma usually stabilizes within 6 to 8 weeks. Most stomas protrude 0.5 inch to 1 inch (1.25 to 2.5 cm) from the abdominal surface.

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? anuria oliguria nocturia urinary retention

anuria Explanation: Absence of urine for a 24-hour period reflects anuria.

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? indwelling urethral catheter intermittent urethral catheter Foley catheter retention catheter

intermittent urethral catheter 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 then inflated to ensure that the catheter remains in the bladder once it is inserted.

A client with urinary incontinence is prescribed incontinence briefs. Which factors should be included in the client education the nurse provides? "Spray perfume or cologne in the briefs before using." "Bathe at least twice per week." "Use the restroom upon waking and at bedtime to reduce the incidence of incontinence." "Cleanse the skin each time you change the briefs."

"Cleanse the skin each time you change the briefs." Explanation: Clients need to change the protective pads or briefs frequently to avoid odor and to prevent skin irritation from prolonged exposure to moisture. Clients should not use cologne or perfume to mask odor, as it may irritate the perineal area. Clients wearing absorbent products should bathe at least daily. Each time the product is changed, the perineal area should be cleansed and examined for any areas of irritation. To reduce the incidence of incontinence, the client should use the bathroom at least every 2 hours during waking hours.

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

"Discard your first urine and begin the collection after that." 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.

A nurse is carrying out a prescription to remove an indwelling catheter. Which explanation should the nurse use with the client prior to removing an indwelling catheter? "I am going to remove the catheter after cutting the tubing and deflating the balloon." "I will need you to hold your breath when I withdraw the tubing." "I want to warn you that intense burning may initially occur." "I am going to remove the catheter after withdrawing the fluid from the balloon."

"I am going to remove the catheter after withdrawing the fluid from the balloon." Explanation: To remove an indwelling catheter, the nurse must withdraw the fluid from the balloon before removing the tubing. If the nurse cuts the tubing, there is no certainty that the full amount of water is removed from the balloon. There is no need for the client to hold the breath or to worry about intense burning under normal circumstances.

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. "I will drink 10 ounces of cranberry juice every day." "I will bathe in the bathtub rather than take a shower." "I will drink about ten 8-oz glasses of water a day." "I will notify my health care provider if my urine starts smelling again." "I will start wearing underwear with a cotton crotch."

"I will drink 10 ounces of cranberry juice every day." "I will bathe in the bathtub 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 eight to ten 8-oz glasses of water daily, notifying the health care provider of any signs of infection (e.g., foul urine odor), and wearing underwear with a cotton crotch are measures to prevent UTIs.

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? "I will place a bath blanket over the client to provide privacy." "The client will be placed in a reclining position with knees bent." "I will use clean gloves to handle the catheter and other equipment." "Washing hands before and after the procedure is important."

"I will use clean gloves to handle the catheter and other equipment." Explanation: Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse. 1493

A school nurse is educating a class of middle school students on how to promote urinary system health. Which statement by one of the students indicates understanding? "I will drink more water to make sure germs do not stay in my body." "I will wear tight pants to prevent germs from entering." "I will tell my parents if I have any symptoms like burning or pain." "I will wipe from front to back after going to the toilet."

"I will wipe from front to back after going to the toilet." Explanation: Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include drying the perineal area after urination or defecation from the front to the back (or from urethra to rectum). Wearing tight pants can trap microorganisms. Drinking water will has no bearing on how long microorganisms stay in the body. Children should always inform parents of any symptoms of illness, but this does not address how to promote urinary health.

A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? "It would be best just to get some adult diapers." "Let me refer you to a urologist who can help you." "Don't worry, this is a normal condition for older adults." "Let's explore structuring activities and toileting breaks."

"Let's explore structuring activities and toileting breaks." Explanation: The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.

A client reports an episode of losing control of urination when a bathroom was not close by. The client states, "I am worried this means that I am starting to lose control of my bladder." What is the appropriate nursing response? "I agree; please make an appointment with your health care provider." "This only happened one time, so it's nothing to worry about." "Let's review your medication history and whether you consume bladder irritants." "I suggest that you invest in incontinence undergarments."

"Let's review your medication history and whether you consume bladder irritants." Explanation: Urge incontinence can be aggravated by bladder irritants, such as caffeine or alcohol, and can take place if diuretics are taken in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the health care provider or to recommend incontinence undergarments.

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. -Clean each labial fold, then the area directly over the meatus. -Advance the catheter until there is a return of urine. -Insert the lubricated catheter into the urethra. -Discard used supplies -Inflate the balloon with the correct amount of sterile saline.

1) Clean each labial fold, then the area directly over the meatus. 2) Insert the lubricated catheter into the urethra. 3) Advance the catheter until there is a return of urine. 4) Inflate the balloon with the correct amount of sterile saline. 5) Discard used supplies.

The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1Void into the provided collection device. 2Clean the area surrounding the urinary meatus with the provided cloth. 3Provide instruction to the client. 4Void a small amount into toilet or bedpan. 5Submit collected specimen to the health care professional. 6Secure the lid on the specimen container.

1) Provide instruction to the client. 2) Clean the area surrounding the urinary meatus with the provided cloth. 3) Void a small amount into toilet or bedpan. 4) Void into the provided collection device. 5) Secure the lid on the specimen container. 6) Submit collected specimen to the health care professional. Explanation: A clean-catch urine specimen is used to obtain a specimen that is clean in nature. The procedure is not sterile. The process requires the nurse to provide the needed education to the client. The client will begin by cleaning the area surrounding the meatus with a provided wipe. The client will void into the toilet or bedpan and discard. The client will next void into the provided specimen container. Once the specimen container is filled the client may finish voiding in the toilet or bedpan and discard. The specimen will need to be secured and submitted to the health care professional.

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? 24-hour specimen clean-catch specimen random specimen intermittent specimen

24-hour specimen Explanation: A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.

Which client should the nurse monitor most closely for signs of urinary retention? A client receiving corticosteroids for acute inflammation A client who suffered pelvic muscle damage in childbirth 6 months ago A client who has been diagnosed with early stage Alzheimer's disease A client with an enlarged prostate

A client with an enlarged prostate Explanation: Urinary retention is often related to an enlarging prostate gland. Pelvic damage more commonly leads to incontinence, not retention. Corticosteroids are not associated with urinary retention. Cognitive deficits are more likely to result in incontinence than urinary retention.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included? Encourage the client to wait to at least 30 minutes before voiding when the urge is felt. 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. Explain to the client that privacy is not important with urination

Assist the client to a normal voiding position when possible. 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.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Administer an IV on the arm high above the access site. Perform venipuncture below the access site to obtain a blood sample for laboratory testing. Measure the client's blood pressure on the arm above the access site.

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Explanation: The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.

The nurse is teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen? Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet. Catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs. Catch the urine while holding the labia apart, after cleansing. Fill the specimen cup. Catch the urine in the cup after cleansing the perineum.

Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet. Explanation: The client should first perform hand hygiene, then separate the labia minora and cleanse the perineum with commercially prepared aseptic swabs, starting in front of the urethral meatus and moving the swab toward the rectum. The client should repeat this cleansing process three times with different cotton balls or swabs, then begin to urinate while continuing to hold the labia apart. Next, the client should allow the first urine to flow into the toilet, followed by holding the specimen container under the urine stream. Then, the client should remove the specimen container, release the hand from the labia, seal the container tightly, and finish voiding. The client then performs hand hygiene again.

Which is true regarding the normal urination? Catheterized clients should drain a minimum of 30 mL of urine per hour. In adults, the average amount of urine per void is 500 mL. Urinary output does not vary all that much between adults and children. In adults, the amount of urine voided typically does not depend on fluid intake and losses.

Catheterized clients should drain a minimum of 30 mL of urine per hour. Explanation: Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.

A client admitted to the hospital with chronic kidney injury suddenly develops the following signs and symptoms: left arm arteriovenous (AV) fistula has weak thrill and bruit; blood pressure 88/40 mm Hg; states feeling dizzy. Which action will the nurse implement first? Notify the primary health care provider. Change to supine position. Instruct to not get out of bed. Examine that clothing is not constrictive on arm.

Change to supine position. Explanation: The client is hypotensive and experiencing dizziness with it, so the first action the nurse must take is to lower the bed to a supine position to help increase the blood pressure by returning the venous blood to the heart. The low blood pressure decreases the strength of blood flow to the AV fistula, which could lead to clotting off the client's access for dialysis. The nurse would instruct the client to not get out of bed, examine the clothing that it is not constrictive on the arm with the AV fistula, and notify the primary care provider of the event, so further orders may be sought.

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action? Gather equipment and supplies. Assess urine characteristics. Explain the procedure to the client. Check electronic health record for medical order.

Check electronic health record for medical order. Explanation: The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after it has been confirmed that an order for irrigation exists.

A client could experience increased urination when using which classification of medication? Cholinergic agents Analgesic medications Central nervous system depressants Stool softeners

Cholinergic agents Explanation: Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination. Analgesics act to relieve pain. Central nervous system depressants are medicines that include sedatives, tranquilizers, and hypnotics. These drugs can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders. Stool softeners makes bowel movements softer and easier to pass.

A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first? Release a small amount of urine into the toilet. Void normally to empty the bladder. Clean each side of the urinary meatus with a separate wipe. Catch a sample of urine in the specimen container.

Clean each side of the urinary meatus with a separate wipe. Explanation: A clean-catch specimen is collected in mid-stream. The nurse will first instruct to clean each side of the urinary meatus, release a small amount of urine, catch a sample, and then complete voiding.

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse will perform what assessment specifically associated with the development of this condition in the older adult? Temperature assessment Assessment for dysuria Cognitive assessment Assessment for nausea

Cognitive assessment Explanation: Symptoms of UTI are different in the older adult, especially if the immune system is depressed. Rather than experiencing painful urination and a high fever, the older adult may become acutely confused. Nausea is not normally associated with UTI's.

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. Contact the health care provider to ask for an order for catheter discontinuation. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). Perform, or allow client to perform, perineal hygiene at least once daily. Ensure that the drainage bag is above the level of the bladder at all times. Discontinue to catheter and report this to the healthcare provider.

Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily. Explanation: The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem? Discuss the use of protective undergarments to avoid embarrassment from incontinence. Encourage the client to confide in family members and tell them about the accidents. Inform the client that this is not normal and make a referral to a urologist. Tell the client that this happens to all people when they get older.

Discuss the use of protective undergarments to avoid embarrassment from incontinence. Explanation: The nurse will promote the client's self-esteem by openly discussing adult undergarments. The client has no other health problems, and can benefit by learning how to self-manage this concern. Encouraging the client to tell family members does not support the client's desire to refrain from telling others about this issue. The client does not need referral to a urologist at this time. Reassuring the client that others have this concern is nontherapeutic and does not directly meet the client's concern.

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. Dry the perineal area after urination or defecation from the back to the front. Take baths instead of showers. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body.

Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body. Explanation: Client education can help prevent UTI recurrence. Teaching the client about measures that promote health and decrease the severity and incidence of UTIs is a major nursing responsibility. The nurse should instruct the client to drink eight to ten 8-oz glasses (1,920 to 2,400 mL) of water daily, drink two 8-oz glasses (480 mL) of water before and after sexual intercourse, void immediately after sexual intercourse, wear underwear with a cotton crotch, and avoid clothing that is tight and restrictive on the lower half of the body. Instruction should include drying the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum, as well as taking showers instead of baths. 1462

When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply. Use powder or lotion in the perineal area. Encourage fluid intake, unless contraindicated. Record volume and character of the urine. Maintain a closed urinary catheter system. Change the indwelling catheter regularly.

Encourage fluid intake, unless contraindicated. Record volume and character of the urine. Maintain a closed urinary catheter system. 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).

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement? Encourage fluid intake. Restrict fluid intake. No action is required. Alert the health care provider of possible infection.

Encourage fluid intake. Explanation: Conservation of fluid by the body during states of underhydration, fever, and diaphoresis results in the production of concentrated urine that is dark in color. A sign of overhydration would be very light or clear urine. Adequate fluid intake would correspond with pale yellow and clear urine. Signs of urinary tract infection include cloudy urine or urine containing blood or blood cells.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next? Have the client drink 8 ounces of water every 15 minutes for 1 hour. Wipe off some of the ultrasound gel and rescan. Ensure proper positioning of the scanner head and rescan. Place the client on either side and rescan.

Ensure proper positioning of the scanner head and rescan. Explanation: The scanner head should be repositioned, and the bladder should be rescanned before assuming that the bladder is truly empty. Additional ultrasound gel may need to be added for the scanner to work properly. If the bladder is truly distended, the client may become more uncomfortable from drinking additional water. The best position for bladder scanning is supine.

The nurse is caring for a client who had an arteriovenous (AV) graft surgically placed. The client is preparing for discharge. Which actions should the nurse teach the client to avoid? Select all that apply. Having blood pressure measurements in the affected arm Getting venipuncture in the affected arm Getting an annual influenza vaccination Carrying heavy items including purses or luggage with the affected arm Sleeping with the affected arm under the head or body

Having blood pressure measurements in the affected arm Getting venipuncture in the affected arm Carrying heavy items including purses or luggage with the affected arm Sleeping with the affected arm under the head or body Explanation: The nurse should educate the caregiver and client to avoid all actions that could impair circulation to the arm with the AV graft present. Decreasing blood flow to the affected arm could result in clotting of the AV graft. Blood pressure and venipuncture should not be attempted in the affected arm. The client should not sleep with the affected arm under the body or head as the weight/compression could decrease blood flow through the graft. Carrying heavy items can compress the graft and impair blood flow causing the graft to clot. Heavy purses or bags over the shoulder of the affected arm can decrease blood flow as well. A client with long-term hemodialysis needs should get an annual influenza vaccination. Discretion should be taken with where the vaccination is injected if prescribed intramuscular.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? Having the client sign a consent form for the procedure Explaining to the client that the procedure will be painful Maintaining the client without liquids before the procedure Inserting a Foley catheter the morning of the procedure

Having the client sign a consent form for the procedure 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 home care nurse visits a client diagnosed with depression who informs the nurse that he has been prescribed amitriptyline. What would the nurse include when educating the client about the effects of this medication? It causes urinary retention. It causes urine to turn blue-green. It decreases sensation of bladder fullness. It decreases glomerular filtrate rate.

It causes urine to turn blue-green. 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. Opioids can decrease the sensation of bladder fullness and the glomerular filtration rate. 1454

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? Loosen the internal muscles used to prevent or interrupt urination. Keep muscles contracted for at least 10 seconds. Relax muscles for at least 5 minutes between Kegels. Perform these exercises two times daily for a week.

Keep muscles contracted for at least 10 seconds. Explanation: Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. Ask the client to bear down until the catheter is expelled. Remove the catheter from the vagina and attempt to insert it into the bladder.

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Explanation: Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.

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

Levodopa 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.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? Calculating the flow rate of urinary output Monitoring the characteristics of the urinary output Assessing PVR using a bladder scanner Palpating the client's bladder region

Monitoring the characteristics of the urinary output Explanation: The effectiveness of therapy is determined by the urine characteristics. On completion of the therapy with continuous bladder irrigation, the client should exhibit urine that is clear, without evidence of clots or debris. The client will have no PVR during therapy. Palpation of the bladder region and calculation of a particular outflow rate do not determine the success or failure of therapy.

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority? Checking for blood return in the CVC Placing the client as N.P.O. status Notifying the health care provider of the assessment findings Obtaining laboratory studies

Notifying the health care provider of the assessment findings Explanation: The assessment is indicative of hospital-acquired catheter infection associated with the CVC. The medical provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Checking for blood return is not indicated and access to the CVC used for hemodialysis should not be attempted without a prescription to do so from the health care provider.

The nurse assesses redness, drainage, and odor to the area around a client's peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? Flushing the catheter with 15 - 20 mL of normal saline Obtaining laboratory studies. Sitting the client up in a greater than a 40-degree angle. Notifying the health care provider of the assessment findings.

Notifying the health care provider of the assessment findings. Explanation: The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter. The health care provider may request laboratory studies, but these cannot be obtained until a prescription is received. Flushing the catheter does not address the likely infection. Sitting the client up may aggravate the pain. The nurse should attempt to keep the client in the most comfortable position possible until a prescription is received from the health care provider.

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? Position the client in a supine position. Administer a diuretic, as ordered. Have the client rest for 15 minutes before the assessment. Assess the client's need for analgesia

Position the client in a supine position. Explanation: Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of what? Protein Calculi Pus Casts

Pus Explanation: Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI. Protein, casts and calculi are all atypical findings in urine but are not definitive for the presence of infection.

A nurse is administering continuous closed bladder irrigation to a client. After performing this intervention, the nurse observes that the irrigation solution is not flowing at the prescribed rate. Which actions should the nurse take? Select all that apply. Raise the bag 3 to 6 in (7.5 to 15 cm). Check the tubing for kinks or pressure points. Open the clamp all the way. Have the client stand, so that gravity can assist the irrigation process. Increase the speed at which the plunger in the syringe is being pushed. Encourage the client to drink a glass of water.

Raise the bag 3 to 6 in (7.5 to 15 cm). Check the tubing for kinks or pressure points. Open the clamp all the way. Explanation: When the irrigation solution is not flowing at the prescribed rate, the nurse should first make sure the clamp is opened all the way and then check the tubing for kinks or pressure points. The nurse may also try raising the bag 3 to 6 in (7.5 to 15 cm) and then checking flow of the irrigation solution. A syringe is used for intermittent, not continuous, closed bladder irrigation. Having the client drink a glass of water or stand will not increase the flow rate of the irrigation solution.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? Moist perineal skin Reddened perineal skin Presence of smegma Absence of discharge

Reddened perineal skin 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.

Which urinary care teaching will the nurse provide to a young adult female client? Wipe from the back to the front. Refrain from douching unless ordered by a health care provider. If you do not feel like voiding, still strain to make sure the bladder is empty. Drink water more frequently in the morning and evening to facilitate hydration

Refrain from douching unless ordered by a health care provider. Explanation: Douching is not recommended unless ordered by the health care provider. Female clients should be taught to wipe from the urinary area towards the rectum to decrease the risk for introducing pathogens into the urethra. Straining is not appropriate. Water should be consumed throughout the day, not just in the morning and evening.

Which urinary care teaching will the nurse provide to a young adult female client? Wipe from the back to the front. Refrain from douching unless ordered by a health care provider. If you do not feel like voiding, still strain to make sure the bladder is empty. Drink water more frequently in the morning and evening to facilitate hydration.

Refrain from douching unless ordered by a health care provider. Explanation: Douching is not recommended unless ordered by the health care provider. Female clients should be taught to wipe from the urinary area towards the rectum to decrease the risk for introducing pathogens into the urethra. Straining is not appropriate. Water should be consumed throughout the day, not just in the morning and evening.

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client? Encouraging the client to stay close to home Fluid restriction Indwelling catheterization Regular toileting routine

Regular toileting routine Explanation: The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.

The nurse completes the task of changing the dressing of a recent surgically inserted peritoneal dialysis catheter. The nurse has applied antibiotic ointment as prescribed, covered the site with 4 × 4 gauze, and labeled the dressing with the date, time of change, and initials of the nurse performing the task. Prior to leaving the client's bedside, the nurse should complete which task next? Secure the tubing of the peritoneal dialysis catheter to the client's abdomen. Replace the linens under the client to decrease moisture. Perform hand hygiene. Ensure that the client's bed is in a locked position.

Secure the tubing of the peritoneal dialysis catheter to the client's abdomen. Explanation: The nurse should secure the tubing to the client's abdomen with tape to prevent any accidental pulling or dislodging of the peritoneal dialysis catheter. Performing a linen change is generally not indicated after changing the dressing. The nurse would perform hand hygiene before the dressing change and upon cleaning up supplies from the bedside and leaving the room. Checking the bed for locked position and verifying the bed is in the lowest position for client safety is important, but it is not the next step associated with the dressing change procedure.

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

Sterile urine specimens may be obtained by catheterizing the client'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 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.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions? The client drinks eight 8-oz glasses of cranberry juice daily. The client soaks in the bathtub daily for perineal care. Since the client is symptom-free, she no longer takes the prescribed antibiotics. The client drinks two glasses of water before and after sexual intercourse

The client drinks two glasses of water before and after sexual intercourse. Explanation: Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions? The client drinks eight 8-oz glasses of cranberry juice daily. The client soaks in the bathtub daily for perineal care. Since the client is symptom-free, she no longer takes the prescribed antibiotics. The client drinks two glasses of water before and after sexual intercourse.

The client drinks two glasses of water before and after sexual intercourse. Explanation: Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal? The client was treated for kidney stones a few months earlier. The client has a history of benign prostatic hyperplasia (BPH; prostate enlargement). The client has had urinary catheters in place repeatedly during previous admissions. The client is acutely confused and has been diagnosed with delirium.

The client is acutely confused and has been diagnosed with delirium. Explanation: A client who is acutely confused is likely unable to manipulate a urinal effectively. Kidney stones, BPH, and previous catheterizations do not preclude the use of a urinal.

A nurse uses a portable bladder ultrasound device to assess bladder volume for a client who is unable to void. Which statement accurately details information needed to interpret the results? The scan is contraindicated for female clients who have had a hysterectomy. The device must be programmed for the biological sex of the client by pushing the correct button on the device. Three separate readings should be obtained over 1 hour and the postvoid residual (PVR) averaged. A PVR of 450 mL is often recommended as the guideline for catheterization.

The device must be programmed for the biological sex of the client by pushing the correct button on the device. Explanation: The device must be programmed for the biological sex of the client by pushing the correct button on the device. If a female client has had a hysterectomy, the male button is pushed. A PVR of >150 mL is often recommended as the guideline for catheterization, because residual urine volumes of >150 mL have been associated with the development of urinary tract infections. It is not necessary to obtain three independent readings.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true? The largest part of a regular bedpan should be placed under the client's buttocks. A regular bedpan is generally more comfortable for clients than a fracture bedpan. A fracture bedpan is preferred for urination and a regular bedpan is preferred for defecation. A fracture bedpan should be used only for clients who have fractures of the femur or lower spine.

The largest part of a regular bedpan should be placed under the client's buttocks. Explanation: The rounded, smooth upper end of the regular bedpan is designed to be placed under the buttocks. Because a regular bedpan is much larger than a fracture bedpan, it is usually less comfortable. Choice of bedpan is based on client characteristics rather than type of elimination. A fracture bedpan can be used for any client.

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? The novice nurse measures the height of the edge of the bladder above the symphysis pubis. The novice nurse asks the client when was the last time he voided before palpating the bladder. The novice nurse observes the lower abdominal wall for any swelling. The novice nurse asks the client to urinate before palpating the bladder.

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—before the bladder is palpated—when the last voiding occurred. 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 nurse is assessing the freshly voided urine of a client. What characteristics of the urine would indicate a urinary problem? Select all that apply. The urine is amber colored. The urine smells like ammonia. The urine pH is 6.0. The urine is translucent. There is pus in the urine. The urine is cloudy.

The urine smells like ammonia. There is pus in the urine. The urine is cloudy. Explanation: The urine specimen that would indicate a urinary problem would possibly smell like ammonia, have pus visible in the sample, and be cloudy in nature. A normal urine sample would be amber colored, translucent, and have a pH around 6.0.

The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include? Tighten the internal muscles used to prevent or interrupt urination. Keep muscles contracted for at least 30 seconds. Relax muscles for at least 1 minute between contractions. Perform these exercises 10 times daily for 1 month.

Tighten the internal muscles used to prevent or interrupt urination. Explanation: Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen three to four times daily for 2 weeks to 1 month. The client should not be instructed to keep muscles contracted for at least 30 seconds, relax muscles for at least 1 minute between exercises, nor perform these exercises 10 times daily for 1 month.

The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence? Stress incontinence Functional incontinence Total incontinence Overflow incontinence

Total incontinence Explanation: Total incontinence may be the result of surgery, trauma, or physical malformation; the client has continuous and unpredictable loss of urine. Stress incontinence is related to an increase in intra-abdominal pressure and commonly occurs during activities such as coughing and sneezing. Overflow incontinence is associated with overdistention and overflow of the bladder, whereby the signal to empty the bladder is lost, the bladder fills, and the client dribbles urine. Functional incontinence occurs because the client is unable to reach the toilet.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true? Unless contraindicated, nurses should encourage clients to stand to use a urinal. If nocturnal incontinence is anticipated, a urinal can be placed between the legs while the client is asleep. Urinals must be replaced every 24 hours to reduce the risk of infection. Both male and female clients commonly void into a urinal in the bathroom to facilitate measurement of urinary output.

Unless contraindicated, nurses should encourage clients to stand to use a urinal. Explanation: A standing position facilitates bladder emptying and decreases the likelihood of spillage of urine. Although female urinals exist, they are more difficult to use and are not commonly used in health care facilities. Replacing urinals every 24 hours is not necessary. A urinal should not be left in place for extended periods of time, because pressure and irritation to the client's skin can result.

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

Urinal Explanation: A urinal is the best choice to collect urine from a nonambulatory male client. If the client is on strict bed rest or confined to bed due to weakness or disability. the client must be positioned in bed in as close to an upright position as feasible. In most instances, the client is able to place and hold the urinal himself. If he is unable to do so, the nurse should hold the urinal in place while the client urinates or place the urinal and leave the client alone for a few moments. A bedpan is not the best choice for a male client who tend to prefer the bottle-like shape of the urinal, although female clients tend to prefer the shape of a bedpan. A specimen hat is for a commode. A large urine collection bag would be used with an indwelling catheter.

The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed? Blood urea nitrogen (BUN) - 7 mg/dL (19.6 mmol/L) Urine culture sensitivity - 100,000/mL Hemoglobin - 16 g/dL Magnesium - 2.5 mEq/L (2.5 mmol/L)

Urine culture sensitivity - 100,000/mL Explanation: 100,000 organisms per milliliter in a 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? Clean the perineal area with a gauze pad and alcohol using a different corner of the gauze with each stroke. Assist the client to a prone position with knees flexed, feet about 2 ft (0.6 m) apart, with legs abducted. Using dominant hand, hold the catheter 1 ft (0.3 m) from the tip and insert slowly into the urethra. 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. 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 1 ft (0.3 m) 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.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. The client's skin is also excoriated from urinary incontinence. Which nursing concern is most appropriate for the nurse to include in this client's car plan? altered skin integrity related to functional incontinence urinary incontinence related to urinary tract infection altered skin integrity related to urinary bladder infection and dehydration urinary tract infection risk related to dehydration

altered skin integrity related to urinary bladder infection and dehydration Explanation: Altered skin integrity related to urinary bladder infection and dehydration would be the appropriate nursing concern for this client's care plan. The nursing concern is the client's excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary tract infection and urinary incontinence are a medical diagnoses. The altered skin integrity is not related to functional incontinence.

The client is a new client in the outpatient wellness clinic. The client reports frequent urinary incontinence of recent onset. The nurse reviews the client's list of medications. Which medication classification will the nurse review with the client to determine when the prescription was started? antihypertensive nonsteroidal anti-inflammatory drug (NSAID) H2-receptor antagonist calcium supplement

antihypertensive Explanation: The nurse wants to determine if the timing of the urinary incontinence correlates with the start of a medication that could promote urinary incontinence. Antihypertensives may increase urinary incontinence, because they cause more fluid to enter into the vascular system. Thus, the fluid would be excreted through the urinary system. The other medication classifications listed do not have urinary incontinence as an adverse reaction.

A nurse has received an order to insert a urinary catheter into a female client. In preparation, the nurse asks if she has ever had an indwelling catheter and, if so, why and for how long. The nurse has performed which action? assessed for the most appropriate size of catheter to insert assessed the possibility that the client has urethral strictures assessed the client's risk of hemorrhage during insertion gauged the client's risk of developing a urinary tract infection

assessed the possibility that the client has urethral strictures Explanation: The nurse has assessed the possibility of urethral strictures, which may make catheter insertion more difficult. This does not relate directly to the client's risk for UTIs or bleeding during insertion. The catheter size is not chosen on this basis.

A client has been hospitalized for 5 days and the nurse is concerned the client is developing a urinary tract infection. Which assessment finding is consistent with a urinary tract infection? absence of sediment in the urine clear, pale, and yellow urine 1,200 ml/day urine output cola-colored urine and fever

cola-colored urine and fever Explanation: Objective indicators of a urinary tract infection (UTI) include cola-colored or dark urine and fever. Indications of a UTI include subjective symptoms such as frequent urination, decreased amount of urine per void, and burning upon urination. Sedimentation in the urine is an abnormal finding and often occurs with a UTI, so absence of sediment is normal. Clear, pale, and yellow urine is a normal finding. The normal daily urine output is between 500 and 3,000 ml/day. Less than 400 ml/day or greater than 3,000 ml/day would concern the nurse but are not commonly associated with UTI.

During his stay in the hospital, a male client 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 this client's care? condom catheter indwelling catheter intermittent catheterization at bedtime toileting the client every 2 hours

condom catheter Explanation: A condom catheter may be used in the care of male clients who lack voluntary control of urination. This is preferable to invasive catheterization (which presents an infection risk). Frequent toileting such as every 2 hours may prevent episodes of incontinence but would significantly disrupt the client's sleep quality.

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? dehydration hypovolemia balanced fluids kidney injury

dehydration Explanation: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The symptoms are not associated with hypovolemia, balanced fluids, nor kidney injury.

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? before bedtime afternoon evening first thing in the morning

first thing in the morning Explanation: While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

A client at a health care facility is being treated for cancer of the bladder. The health care provider uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion? inability to control either urinary or bowel elimination hygiene measures used to keep meatus and adjacent area of the catheter clean use of a catheter to collect urine in a sterile environment one or both of the ureters are surgically implanted elsewhere

one or both of the ureters are surgically implanted elsewhere 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.

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? urge reflect stress total

stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Other types of incontinence have different causative factors.

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, colorless strongly aromatic, dark amber

strongly aromatic, dark amber Explanation: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.

The school nurse is caring for a student who experienced a seizure in the classroom. The student was noted to lose a large amount of urine during the seizure. Which type of incontinence does the nurse anticipate the client may have experienced? total urge reflex stress

total Explanation: Total incontinence takes place without a pattern or warning, and without client control, often in the presence of altered consciousness. Other types of incontinence have different causative factors.

The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will: urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." use three wipes provided; one to clean each side of the urinary meatus, and one in the middle from front to back." wash my hands before collecting the clean catch urine specimen." keep the labia spread after cleaning and during collection of the specimen."

urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." Explanation: The client accurately details the steps of the procedure except the nurse needs to further instruct the client that the client needs to void a small amount of urine into the toilet and then stop urination for a short time and then void around 3 to 5 mL into the cup.