Chap 37 Urine Elimination
A client with a new urostomy requires teaching by the nurse. The nurse will construct the plan of care and education based upon which primary nursing diagnosis? Select all that apply. risk for impaired skin integrity stress urinary incontinence risk for infection situational low self-esteem functional urinary incontinence
risk for impaired skin integrity risk for infection situational low self-esteem Explanation: The client with a new urostomy may be at risk for impaired skin integrity and infection if the client does not care properly for the ostomy. Therefore, the nurse will use these nursing diagnoses to plan care and education. The client may also experience a change in self-esteem due to this different way of elimination. The client will not experience types of incontinence, since the urostomy will continually drain urine. Chapter 37: Urinary Elimination - Page 1353
A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? urge total reflex stress
stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control. Chapter 37: Urinary Elimination - Page 1356
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 woman using an intrauterine device for contraceptive reason is at risk for developing a UTI." "I will make sure to teach my clients with diabetes mellitus to control their glucose level to help prevent a UTI." "Having sexual relationships does not put a woman at risk for developing a UTI." "Due to the physiologic changes with aging, the elderly are at risk for developing a UTI."
"Having sexual relationships does not put a woman at risk for developing a UTI." Explanation: During sexual intercourse, bacteria from the perineal area may travel into the urethra and urinary bladder. The spermicide used with the diaphragm decreases the vagina's normally protective flora. The glucose in the urine acts as an excellent medium for bacteria to proliferate in the client with diabetes mellitus. Older adults are predisposed to development of urinary tract infections due to the physiologic changes associated with aging. Chapter 37: Urinary Elimination - Page 1360
A male client informs the nurse that he is concerned about dribbling and incontinence of small amounts of urine after the removal of an indwelling urinary catheter. The nurse is aware that the catheter was in place for 3 weeks prior to being removed. Which is the nurse's best response to the client? "It will take a little while for the bladder to reestablish control as the strength of the muscle improves, and an accident is not unusual." "Dribbling and incontinence often mean the bladder has lost muscle tone, and the catheter will likely need to be reinserted." "Your symptoms are a normal part of the aging process. The bladder loses tone as you age." "I will inform the health care provider, and we will likely need to perform a cystoscopy to look at your bladder to look for problems."
"It will take a little while for the bladder to reestablish control as the strength of the muscle improves, and an accident is not unusual." Explanation: The client needs to be taught that after the removal of an indwelling urinary catheter, it may take a little while for the bladder to reestablish voluntary control as the muscle tone returns. Enuresis is not unusual, but this does not mean the client needs the catheter reinserted. The symptoms are not part of the aging process, and the health care provider does not need to be informed. The information and teaching should be documented in the client's chart. Chapter 37: Urinary Elimination - Page 1371
The health care provider has prescribed an indwelling catheter for a 48-year-old male client who is in traction with leg fractures. Which information will the nurse give the client when he states not wanting the indwelling catheter? "This is the only option for catheterization." "This is what your health care provider has prescribed." "Indwelling catheters do not hurt, and I will be careful placing it." "Let me talk to your health care provider about a condom catheter." TAKE ANOTHER QUIZ
"Let me talk to your health care provider about a condom catheter." Explanation: The nurse will support the client's autonomy by investigating other options, such as a condom catheter. It is nontherapeutic to discount the client's concern or to tell the client that this is the only catheterization option. Chapter 37: Urinary Elimination - Page 1364
A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm 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 is 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. Chapter 37: Urinary Elimination - Page 1346
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. Chapter 37: Urinary Elimination - Page 1353
The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take? Inform the client that the health care provider will be contacted. Ask the client why he or she does not want a catheter. Gather appropriate supplies to teach the client to perform straight catheterization. Continue to place the indwelling catheter because it has been prescribed.
Ask the client why he or she does not want a catheter. Explanation: The nurse should inquire, using open-ended questioning, why the client does not want a catheter. This may allow the nurse to provide needed education. Reporting to the health care provider may be necessary but not without all of the facts about the situation. The nurse should not implement straight catheterization without a health care provider's prescription. It is unethical and inappropriate to continue to place the catheter without the client's consent.Catheters, p. 1365. Chapter 37: Urinary Elimination - Page 1365
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. Chapter 37: Urinary Elimination - Page 1376
What accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter? Use clean technique when inserting a catheter. Maintain an open system whenever possible. Use the largest appropriate-sized catheter in order to prevent leakage. Avoid irrigation unless needed to relieve an obstruction.
Avoid irrigation unless needed to relieve an obstruction. Explanation: Irrigation should be avoided to prevent infection unless there is an obstruction. A closed system should be maintained using sterile technique. The smallest appropriate-sized catheter should be used. Chapter 37: Urinary Elimination - Page 1370
The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next? Frequency of urine Intake and output Blood pressure Blood sugar
Blood sugar Explanation: Glycosuria is a condition that describes the finding of glucose in the urine. The natural next step would be to obtain a fingerstick for blood glucose level. Vital signs are a baseline indicator of any illness or injury. Intake and output may be important going forward, but the diagnosis directs the next action. Chapter 37: Urinary Elimination - Page 1347
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? Incontinence after the age of 3 years is not normal. Boys may take longer for daytime continence than girls. Boys may walk by 1 year and should be continent by 3 years. Daytime continence is usually not achieved by boys until age 5.
Boys may take longer for daytime continence than girls. 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. Chapter 37: Urinary Elimination - Page 1346
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. Chapter 37: Urinary Elimination - Page 1356
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. Chapter 37: Urinary Elimination - Page 1347
A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? Monitor vital signs Contact the health care provider Encourage fluids Instruct on proper wiping technique
Contact the health care provider Explanation: The term pyuria refers to the presence of pus in the urine. The nurse should first contact the health care provider, as antibiotic therapy may be necessary. Encouraging fluids, instruction on wiping technique and monitoring vital signs will follow. Chapter 37: Urinary Elimination - Page 1347
A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women? Contract abdominal muscles 10 times per day. Squat down and then jump up to a standing position. Lie on the floor, raise, then lower your legs 20 times per day. Contract the pubic muscles for 3 seconds, then relax.
Contract the pubic muscles for 3 seconds, then relax. Explanation: Pelvic floor exercises, or Kegel exercises, strengthen the pubococcygeal muscles and effectively promote urinary control. The nurse should inform the women to locate the muscles used to start and stop urinating. Then contract those muscles and relax them repeatedly. Strengthening the abdominal muscles will not help with urinary control. Squatting, jumping, and performing leg lifts will help to strengthen the quadriceps and hamstrings. Chapter 37: Urinary Elimination - Page 1359
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. Chapter 37: Urinary Elimination - Page 1360
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. Chapter 37: Urinary Elimination - Page 1380-1383
A nurse is caring for a female client with an indwelling urinary catheter. Which action should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? Use clean technique when inserting the catheter. Ensure that the catheter is removed as soon as possible. Irrigate the catheter with sterile water once per shift. Administer prophylactic antibiotics, as ordered. TAKE ANOTHER QUIZ
Ensure that the catheter is removed as soon as possible. Explanation: To prevent UTIs, the nurse should leave the catheter in place for as short a time as possible. Strict aseptic technique is used for insertion, not clean technique. Frequent irrigation increases the risk of UTIs. For most clients with intact immune systems, prophylactic antibiotics are not used. Chapter 37: Urinary Elimination - Page 1391-1397
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? Remove the catheter every 8 hours, or more often in humid weather. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application. Fasten the condom securely enough to prevent leakage without constricting blood flow. Ensure the tip of the tubing is touching the tip of the client's penis.
Fasten the condom securely enough to prevent leakage without constricting blood flow. Explanation: Nursing care of a client 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 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area. Chapter 37: Urinary Elimination - Page 1389-1391
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. Chapter 37: Urinary Elimination - Page 1396
A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved? Glomerulus Bowman's capsule Loop of Henle Nephron
Nephron 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. Chapter 37: Urinary Elimination - Page 1342
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. Chapter 37: Urinary Elimination - Page 1375-1376
A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? Placing the client as N.P.O. status. 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. There is no indication to withhold oral food or fluids from the client at this time. 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. Chapter 37: Urinary Elimination - Page 1377
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. Chapter 37: Urinary Elimination - Page 1380-1382
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. Chapter 37: Urinary Elimination - Page 1378
Definition of: Spermicide anuria oliguria nocturia
Spermicide is a chemical that kills sperm. It's found in creams, films, foams, gels, and suppositories often available at any drugstore Anuria is the failure of the kidneys to produce urine. Oliguria is the production of abnormally small amounts of urine. Nocturia is a condition in which you wake up during the night because you have to urinate. Causes can include high fluid intake, sleep disorders and bladder obstruction. Treatment of nocturia includes certain activities, such as restricting fluids and medications that reduce symptoms of overactive bladder.Jan
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."
Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse. Reference: Chapter 37: Urinary Elimination - Page 1392
The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client? The birth can cause perineal swelling. A neurogenic bladder results from local anesthesia. A urinary tract infection results from the birth process. Catheterization is necessary for 1 week.
The birth can cause perineal swelling. Explanation: Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period. Chapter 37: Urinary Elimination - Page 1364
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?
The client 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 client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large. Reference: Chapter 37: Urinary Elimination - Page 1403
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. Chapter 37: Urinary Elimination - Page 1386-1388
A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? The client is on a low protein diet. The client is dehydrated. The client has a history of osteoarthritis. The client is lactose intolerant.
The client is dehydrated. Explanation: The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function. Chapter 37: Urinary Elimination - Page 1355
A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client? This urinary diversion is only temporary. The client will need to change the urinary pouch every 4 hours. The client will have to wear an external appliance to collect urine. Urination can be voluntarily controlled after the stoma heals from the initial surgery.
The client will have to wear an external appliance to collect urine. Explanation: An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often. Chapter 37: Urinary Elimination - Page 1405-1409
Use of an indwelling urinary catheter leads to the loss of bladder tone. True False
True Explanation: People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma. Chapter 37: Urinary Elimination - Page 1346
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. 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. Chapter 37: Urinary Elimination - Page 1351
A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Perform hand hygiene between cleansing the woman's labia and inserting the catheter. Insert the catheter with her left hand while supporting the woman with her right hand.
Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Explanation: Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand. Chapter 37: Urinary Elimination - Page 1391-1398
The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?
Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. Explanation: The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder. Chapter 37: Urinary Elimination - Page 1352-1353
A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority? Using an appropriate measuring container Wearing gloves when handling the urine Measuring the urine container at eye level Noting the color and clarity of the urine
Wearing gloves when handling the urine 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. Chapter 37: Urinary Elimination - Page 1349
A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic.
Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. Explanation: When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens and aseptic technique. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic. Chapter 37: Urinary Elimination - Page 1353
The nurse is caring for a group of clients on the acute care unit. Which client(s) will benefit from urinary catheterization? Select all that apply. a client in septic shock that is unresponsive a client that developed a urinary tract infection a client that is unable to mobilize to the bathroom following abdominal surgery a confused client that requires a sterile urine specimen to be obtained a client with an enlarged prostate that is unable to void
a client in septic shock that is unresponsive a confused client that requires a sterile urine specimen to be obtained a client with an enlarged prostate that is unable to void Explanation: Reasons for urinary catheterization include monitoring acutely ill clients, obtaining sterile urine specimens from clients who cannot otherwise provide them, and relieving urinary retention. The presence of a urinary tract infection does not necessarily indicate a need for catheterization. A client who is immobile should be introduced to the use of a bedpan or commode. Chapter 37: Urinary Elimination - Page 1364-1365
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. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019, Chapter 37: Urinary Elimination, p. 1347. Chapter 37: Urinary Elimination - Page 1347
When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine? dehydration infection stasis blood
blood 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. Chapter 37: Urinary Elimination - Page 1347
A woman is reporting bladder urgency. It is most important to assess: exercise. weight. caffeine intake. vitamin supplements.
caffeine intake. Explanation: Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts. Chapter 37: Urinary Elimination - Page 1358
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? checking that the client has signed 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
checking that the client has signed 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 by the procedural health care provider after explaining the purpose, risks, and benefits of the procedure. The will check that this consent is signed before the procedure beings. The client does not need to have fluids withheld nor 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. Chapter 37: Urinary Elimination - Page 1354
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. Chapter 37: Urinary Elimination - Page 1348
A 57-year-old man is suffering from polyuria. What can cause polyuria? diabetes insipidus renal disease urinary tract infection renal calculi
diabetes insipidus Explanation: Untreated diabetes insipidus can cause an increase in the formation and excretion of urine without a concurrent increase in fluid intake. Renal disease often leads to oliguria and even anuria, a decrease in urine outputs. Urinary tract infections cause an increase in frequency but not necessarily an increase in the amount of urine that is produced. Renal calculi can cause hematuria. Chapter 37: Urinary Elimination - Page 1347
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. Chapter 37: Urinary Elimination - Page 1352-1353
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. Chapter 37: Urinary Elimination - Page 1365
Diabetes insipidus
is an uncommon disorder that causes an imbalance of fluids in the body. This imbalance makes you very thirsty even if you've had something to drink. It also leads you to produce large amounts of urine.
A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a: cystocele. enuresis. overactive bladder. neurogenic bladder.
neurogenic bladder. Explanation: Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both. Chapter 37: Urinary Elimination - Page 1364
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. 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. Chapter 37: Urinary Elimination - Page 1348
A nurse is caring for a client who has an infant age 4 months. 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? reflex incontinence stress incontinence urge incontinence functional incontinence
stress incontinence Explanation: The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to giving birth. 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. Chapter 37: Urinary Elimination - Page 1361