ATI Urinary Elimination - practice assessment
A nurse is planning on teaching a client who is scheduled for an intravenous pyelogram (IVP). Which of the following statements should the nurse include in the teaching? - "The procedure will be cancelled if the urinalysis indicates the presence of red blood cells." - "High frequency sound waves will be used to identify renal system structures." - "You will be able to resume your regular diet as soon as the test is complete." - "After the procedure you will be encouraged to drink plenty of fluids."
"After the procedure you will be encouraged to drink plenty of fluids." The nurse should encourage fluid intake after the procedure to help promote elimination of the dye used during the procedure.
A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? "I drink at least 2 quarts of fluid every day." "The last time I voided it was painful and red-tinged." "My period ended 2 days ago." "I don't eat shellfish because it gives me hives."
"I don't eat shellfish because it gives me hives." The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.
A nurse is instructing a female client on obtaining a midstream urine specimen. Which of the following statements by the client indicates an understanding of the teaching? "I will wipe from the back to front with the cleansing cloth." "I should not collect a urine sample when I am menstruating." "I should let the urine cool to room temperature before sending it to the lab." "I need to urinate a small amount in the toilet before collecting the sample."
"I need to urinate a small amount in the toilet before collecting the sample." The client should begin the stream of urine in the toilet first, and then pass the container through the urine stream to obtain the sample. This action will wash off any bacteria at the distal urethra that could contaminate the sample.
A nurse instructs a female client about collecting a midstream urine sample. Which of the following client statements indicates an understanding of the procedure? "I'Il urinate a little then stop." "I'Il use the cleansing wipe from front to back." "I'Ill clean the inside of the container with a wipe." "I'll use each cleansing wipe twice."
"TIl use the cleansing wipe from front to back." The client should cleanse the perineal area from front to back to avoid introducing bacteria from the anal area into the area of the urinary meatus.
A nurse is teaching a client who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching? "You should limit fluids for 12 hr following the procedure." "You may have pink-tinged urine after this procedure." "You can eat a full liquid meal up to 1 hour before the procedure." "You will be placed on your right side during the procedure."
"You may have pink-tinged urine after this procedure." The client might have blood-tinged, or pink, urine after the procedure. The client should report dark red urine because it is an indication of bleeding.
A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.) "Your provider might prescribe anticholinergic medications." "You should limit fluids in the evening." "You should restrict your intake of caffeine." "You might require intermittent urinary catheterization." "You might require an anterior vaginal repair."
"Your provider might prescribe anticholinergic medications" Anticholinergic medications suppress bladder contractions and increase bladder capacity. "You should limit fluids in the evening" . Limiting fluid intake in the evening prior to bedtime helps prevent an overload of fluid in the bladder during hours of sleep. "You should restrict your intake of caffeine" The restriction of caffeine is effective in the treatment of urge incontinence because caffeine is a bladder irritant.
A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client? - "If the medicine causes an upset stomach, take an antacid at the same time." - "Limit your daily fluid intake while taking this medication." - "This medication can cause photophobia, so be sure to wear sunglasses outdoors." - "You should report any tendon discomfort you experience while taking this medication,"
- "You should report any tendon discomfort you experience while taking this medication," The nurse should instruct the client to report any tendon discomfort as well as swelling or inflammation of the tendons due to the risk of tendon rupture.
A nurse is preparing a sterile field prior to inserting a urinary catheter for a client. Identify the sequence of steps the nurse should plan to follow. (Move the steps into the box on the right, placing them in order of performance. Use all the steps.) Perform hand hygiene Place package on work surface. Open outermost flap away from self, Open innermost flap toward self. Open side flap, pulling to the side. Use inner surface of package as sterile field.
- perform hand hygiene - place package on work surface - open outermost flap away from self - side flaps moving to the side - open the innermost flap, toward self - use innermost surface of package as sterile field
A nurse is monitoring the urinary output of an adult client who had a colon resection. Which of the following 24 hr output totals indicates oliguria? 720 mL 550 mL 380 mL 600 ml
380 mL This urinary output indicates oliguria, which is defined as less than 400 mL of total output in 24 hr or less than 30 ml per hr.
A client who has an elevated BUN is most likely to have a manifestation of A client who reports painful urination of a A client who reports urinary frequency A client who has glucose in his urine
A client who reports urinary frequency Voiding a small amount of urine (less than 100 mL) frequently (2 to 3 times per hr), and dribbling of urine are manifestations of urinary retention.
A nurse is providing discharge teaching to a client who will be performing intermittent self-catheterization. Which of the following instructions should the nurse include? Use sterile technique during the insertion procedure. Inflate the catheter balloon with 20 mL of sterile water. Advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow. Use water to lubricate the catheter tip prior to inserting it.
Advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow. The nurse should instruct the client to advance the catheter 2.5 to 5 cm (1 to 2 in) after urine begins to flow to make sure that it is completely in the bladder.
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). The nurse should plan to administer the client's PRN bethanechol when the client reports which of the following manifestations? Bladder spasms Severe pain. An inability to void Frequent episodes of painful urination
An inability to void Bethanechol is a cholinergic medication that stimulates the parasympathetic nervous system, thus improving the tone and motility of the smooth muscles of the urinary tract enough to initiate urination.
A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown? Apply a moisture barrier ointment to the client's skin. Clean the client's skin and perineum with hot water after each episode of incontinence. Check the client's skin every 8 hr for signs of breakdown. Request a prescription for the insertion of an indwelling urinary catheter.
Apply a moisture barrier ointment to the client's skin. Skin that remains in contact with urine for prolonged periods is at risk for maceration and should apply a moisture barrier ointment to prevent further contact of the skin with urine. breakdown. After cleansing and drying the client's skin, the nurse
A nurse is caring for a client who has an indwelling urinary catheter and notes blood-tinged urine in the catheter bag. The nurse recognizes this finding can be a manifestation of which of the following urinary alterations? Pernicious anemia Dehydration Prostate enlargement Bladder infection
Bladder infection The nurse should recognize that hematuria, or blood-tinged urine, can be a manifestation of a bladder or kidney infection.
A nurse is caring for a client who is 5 hr postoperative following a transurethral resection of the prostate (TURP). The nurse notes that the client's indwelling urinary catheter has not drained in the past hour. Which of the following actions should the nurse take first? Notify the provider. Check the tubing for kinks. Adjust the rate of the bladder irrigant. Irrigate the catheter.
Check the tubing for kinks. When providing client care, the nurse should first use the least restrictive intervention; nurse must ensure constant flow of the bladder irrigant into the catheter and outward drainage therefore, the nurse should check the catheter tubing for kinks. The from the catheter to prevent clotting, which could occlude the catheter lumen.
A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? Urinary retention Low back pain Incontinence Confusion
Confusion Confusion is a clinical finding of UTis specifically associated with older adult clients.
A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client? Nephrosclerosis Uremia Diverticulitis Cystitis
Cystitis A sudden anset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult
A nurse is reviewing the medical record of a client who has a urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor? COPD Diabetes mellitus Anemia Osteoporosis
Diabetes mellitus Diabetes mellitus is a risk for factor for a UTI due to the increased amount of glucose present in the urine.
A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization? Urge incontinence Dribbling of urine Weight gain Rectal distention
Dribbling of urine Dribbling of urine, or overflow incontinence, is an indicator of bladder distention. The nurse should perform intermittent catheterization when this occurs to prevent bladder trauma or infection. A regular schedule to drain the flaccid bladder should be established, with no longer than 8 hr. between catheterizations.
A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections, Which of the following actions shouid the nurse include in the client's plan of care? Cleanse the perineum from back to front. Obtain a prescription for an indwelling urinary catheter. Encourage fluid intake at and between meals. Offer the client the bedpan every 2 hr.
Encourage fluid intake at and between meals. Increased fluid intake dilutes the urine, reduces stasis, and greatly reduces the urinary bacterial count. Consequently, the risk of nosocomial (hospital- acquired) UTI is reduced, even for a client who has a spinal cord injury.
A nurse is implementing a bladder retraining program for a client. Which of the following actions should the nurse take? Assist the client to the bathroom every 2 hr. Restrict oral fluid intake during waking hours. Encourage the client to hold her breath when feeling the urge to urinate. Provide adult diapers until bladder retraining is successful.
Encourage the client to hold her breath when feeling the urge to urinate. The nurse should encourage the client to take deep, slow breaths to help diminish the urge to urinate.
A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan? Instruct the client to take antibiotics until dysuria is no longer present. Instruct the client to avoid drinking carbonated beverages. Instruct the client to drink 240 mL of tomato juice each day. Instruct the client to drink 1 Lof fluid each day.
Instruct the client to avoid drinking carbonated beverages. The nurse should instruct the client to avoid drinking carbonated beverages and caffeine to reduce bladder irritation.
A charge nurse is observing a newly-licensed nurse insert an indwelling urinary catheter for a male client. Which of the following actions by the newly-licensed nurse requires intervention by the charge nurse? - Lubricates the first 2.5 to 5 cm (2 in) of the catheter. - Dons sterile gloves before cleaning the client's meatus. - Secures the tubing to the client's upper thigh. - Pulls gently on the catheter to check for resistance after inflating the balloon.
Lubricates the first 2.5 to 5 cm (2 in) of the catheter. The nurse should lubricate the first 2.5 to 5 cm (1 to 2 in) of the catheter when inserting a catheter into a female client. The nurse should lubricate the first 15 to 17.5 cm (6 to 7 in) when inserting a catheter into a male client. cleaning the client's meatus.
A nurse in a clinic is assessing a client who has a new diagnosis of interstitial cystitis. The nurse should expect which of the following Negative urine culture Denies urgency Denies pain with urination Fever
Negative urine culture A laboratory finding of a negative urine culture is consistent with a diagnosis of interstitial cystitis since it is a non-infectious process.
A nurse is assessing a client who has a urine output of 250 mL in a 24-hr period. Which of the following descriptive terms should the nurse place in the client's electronic record? Enuresis Anuria Nocturia Oliguria
Oliguria The nurse should document the client has oliguria, which is urine output between 100 mL and 400 mL of urine in 24 hr.
A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? Stress incontinence Urge incontinence Overfiow incontinence Reflex incontinence
Overflow incontinence These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.
A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine? Pale pink Bright yellow Bright red Dark amber
Pale pink The client should expect to pass some small clots and tissue in his urine for few a days, which may give the urine a pale pink color. By 2 to 3 days after surgery, around the time of discharge, his urine should be clear yellow.
A nurse is caring for a client who has not voided for 8 hr following the removal of an indwelling urinary catheter. Which of the following actions should be the nurse take first? Increase fluids. Perform a bladder scan. Insert a straight catheter. Provide assistance to bathroom,
Perform a bladder scan. The first action the nurse should take using the nursing process is to assess the client. The nurse should assess the post void residual (PVR) using a bladder scanner.
A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control? Shakes the soiled linen to remove any toilet paper remnants Places the soiled linen on the floor before bagging it Holds the solled linen against her body while carrying it to the linen bag Places clean linen that touched the floor in the soiled linen bag
Places clean linen that touched the floor in the soiled linen bag Linen that touches the floor or the AP drops requires laundering.
A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first? Deflate the catheter balloon using a sterile syringe. Measure and document the urine in the drainage bag. Remove the tape or device securing the catheter to the client's thigh Position the client supine.
Position the client supine. The first action the nurse should take using the nursing process is to place the client in a supine position. This permits adequate visualization and assessment of the perineal area and promotes client comfort and relaxation.
A nurse who is left-handed is preparing to perform a straight catheterization for a client. Which of the following actions should the nurse take? Raise the side rail on the working side of the bed. Use the non-dominant hand to insert the catheter. Stand on the left side of the bed. Raise the bed to a comfortable height.
Raise the bed to a comfortable height. The nurse should raise the bed to a comfortable height to prevent personal musculoskeletal injury.
A nurse is discussing indications for urinary catheterization with a newly licensed nurse. Which of the following indications should the nurse include? Select all that apply. Relief of urinary retention Convenience for the nursing staff or the client's family Measurement of residual urine after urination Routine acquisition of a urine specimen An open perineal wound
Relief of urinary retention Measurement of residual urine after urination An open perineal wound Valid indications for urinary catheterization include urinary retention, bladder distention, management of urinary elimination for clients who have spinal cord injuries, and prevention of urethral obstruction from blood clots following genitourinary surgery.
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.) Report of feeling pressure Tenderness over the symphysis pubis Distended bladder Voiding 30 ml frequently - Dysuria
Report of feeling pressure Distended bladder Dysuria Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a report of feeling pressure. Tenderness over the symphysis pubis is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include tenderness over the symphysis pubis. Distended bladder is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include a distended bladder, Voiding 30 ml frequently is correct. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Clinical findings of urinary retention include frequent voiding of 25 to 60 mL of urine. Dysuria is incorrect. Urinary retention is commonly seen in clients diagnosed with prostatic hypertrophy. Dysuria, or painful burning with urination, is not a finding associated with urinary retention.
A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior? Remind the client to tell the nurse when he has to urinate. Use adult diapers to prevent frequent clothing changes. Take the client to the bathroom every 2 hr. Request a prescription for an indwelling urinary catheter.
Take the client to the bathroom every 2 hr. By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal? Temporary urinary retention Urinary frequency for several days Blood-tinged urine Highly concentrated urine
Temporary urinary retention Until the bladder regains its full tone, it is common for clients to develop urinary retention, If a client does not urinate for 6 to 8 hr after catheter removal, reinsertion might become necessary.
A charge nurse is observing a nurse insert an indwelling urinary catheter into a female client. For which of the following actions by the nurse should the charge nurse intervene? The nurse separates the client's labia with her dominant hand. The nurse coats the indwelling urinary catheter with lubricant. The nurse provides perineal care prior to inserting the urinary catheter. The nurse applies the sterile drape prior to inserting the urinary catheter.
The nurse separates the client's labia with her dominant hand. The nurse should use her non-dominant hand to separate the labia, or to hold the penis in male clients. The dominant hand is the hand that should handle the catheter during insertion and when filling the balloon. If the nurse separated the labia with her dominant hand, it would be more difficult to insert the catheter in a sterile environment and could result in introduction of bacteria into the urinary tract.
A nurse is caring for a client and observes that the client's urine is dark amber, cloudy, and has an unpleasant odor. The nurse should recognize that these findings are associated with which of the following? Urinary tract infection Urinary incontinence Urinary frequency Urinary retention
Urinary tract infection A client who has a urinary tract infection has urine that appears cloudy and concentrated because of the presence of WBCS, RBCS and bacteria, The urine often has an unpleasant odor.
A nurse is providing discharge teaching about clean intermittent self-catheterization for a client who has benign prostatic hyperplasia. Which of the following instructions should the nurse include? Perform catheterization when you recognize the urge to void. Hold the penis at a 30° to 45° angle when inserting the catheter. The client should Inflate the balloon when the urine flow stops. Use soap and water to wash the catheter after each use.
Use soap and water to wash the catheter after each use. The client should wash the catheter using soap and water and store it in a clean container after each use.
A nurse is reviewing the medication record for a client who has chronic kidney disease. Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity? Omeprazole Vancomycin Ondansetron Diphenhydramine
Vancomycin The nurse should identify that vancomycin, an antibiotic, to be associated with nephrotoxic adverse effects.
A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take? Insert the needle into the neediess port at a 60° angle. Withdraw 3 to 5 ml of urine from the port. Wipe the area of needleless port with sterile water. Don sterile gloves.
Withdraw 3 to 5 ml of urine from the port. The nurse should withdraw the required amount of urine which would be approximately 3 to 5ml for a urine culture or 30 mL for a routine urinalysis.
