Chapter 38: Urinary Elimination

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?

Total incontinence

A nurse is administering intermittent closed catheter irrigation to a client. Place the following steps in the correct order. Use all options.

Cleanse the access port on the catheter with an antimicrobial swab. Clamp or fold the catheter tubing below the access port. Attach the syringe to the access port on the catheter using a twisting motion. Gently instill solution into the catheter. Remove the syringe from the access port. Unclamp or unfold the tubing and allow the irrigant and urine to flow into the drainage bag.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted?

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

A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause?

"Have you ever had an elevated blood sugar?" Polyuria means greater than normal urinary elimination. Untreated diabetes insipidus and hyperglycemia can greatly increase urine output. Ingestion of diuretics, caffeine, and alcohol also results in polyuria. Kidney disease is associated with a lack of urine output.

A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client?

"How frequently do you urinate each day?"

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?

"Let's review your medication history and whether you consume bladder irritants."

A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?

"One signal of preparedness is when your child is dry for at least 2 hours."

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

"Void a small amount, stop, and discard it."

The nurse has an order to obtain a urine specimen from a client with an indwelling Foley catheter. Which supplies would the nurse need to gather? Select all that apply.

10-mL (milliliter) syringe Sterile specimen container Antiseptic swab

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24-hour specimen 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.

A client admitted to the hospital with chronic renal failure suddenly develops the following signs and symptoms: left arm arteriovenous (AV) fistula has weak thrill and bruit; BP 88/40 mm Hg; stated feels dizzy. Which action would the nurse implement first?

Change to supine position. 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.

A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first?

Clean each side of the urinary meatus with a separate wipe.

The nurse is caring for a client diagnosed with a urinary tract infection. The primary care provider orders include an antibiotic, an antipyretic, and a urine culture and sensitivity, and urine specimen for nitrates. Which actions should the nurse take? Select all that apply.

Collect the first void clean urine specimen since the client presented in the emergency department at 0500. Obtain the urine specimens before beginning the ordered antibiotic. Instruct the client on the midstream urine collection process. Place the collected specimen with proper label in a biohazard bag and send it to the lab after collection.

During the well-child checkup for 2-year-old twins (one boy, one girl), their mother asks the nurse about preparing to toilet train the children. What information can be provided to the parent? Select all that apply.

Daytime incontinence is not a concern while toilet training Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training. Children old enough to undress themselves will have increased abilities to toilet train.

The health care provider has ordered a 24-hour urine specimen collection for a client. Which nursing action is appropriate? Select all that apply.

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.

The nurse is assessing a client with a urinary sheath catheter. After removing the catheter, the nurse observes a break in skin integrity on the penis. What actions by the nurse would be appropriate at this time? Select all that apply.

Do not reapply the urinary sheath Allow the skin to be open to air as much as possible Arrange for a consult with a wound nurse

A client is prescribed an indwelling urinary catheter for 2 days prior to surgery. Which action should the nurse take to decrease the occurrence of health care-associated infection (HAI) for this client?

Encourage fluid intake.

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?

Ensure proper positioning of the scanner head and rescan. 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.

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)?

Ensure that the catheter is removed as soon as possible.

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.

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?

Levodopa

When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply.

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

The nurse is catheterizing a male urinary bladder, and urine leaks out of the meatus around the catheter. Which actions would the nurse perform next? Select all that apply.

Make sure the smallest sized catheter with a 10-mL balloon is used. Consider an evaluation for urinary tract infection. Ensure that the correct amount of solution was used to inflate the balloon.

A nurse is caring for a female client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action?

Many clients find it embarrassing or degrading to use a bedpan.

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. The client has been diagnosed with an enlarged prostate. Which should the nurse include in the client education to encourage urination? Select all that apply.

Meditate while urinating Do Kegel exercises 3 to 5 times per day Try double voiding Avoid antihistamines Do not delay urination To improve emptying of the bladder when a man has been diagnosed with an enlarged prostate, Kegel exercises 3 to 5 times per day can help with bladder control and function. Nervousness and tension cause some men to have difficulty urinating and meditation along with exercise can help to reduce stress. Double voiding, urinating and then trying to go again a few moments later can be helpful. This will help to fully empty the bladder, lessen the feeling of constantly having to urinate, and maybe save another trip to the bathroom. The client should avoid antihistamines and decongestants. These medicines tighten the muscles around the urethra, making it harder to urinate. The nurse should encourage the client to urinate when the urge presents.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment?

Monitoring the characteristics of the urinary output

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron

The nurse is reviewing a urinalysis laboratory report of a client. The nurse notes there are nitrates and white blood cells present in the urine. Based on these results, what intervention(s) would be necessary? Select all that apply.

Notify the health care provider. Prepare to obtain a urine culture. Prepare to obtain a specimen by catheterization.

A nurse is collecting a routine urinalysis on a client presenting to the emergency room with abdominal pain. What nursing action is important in the collection of this specimen?

Obtain a nonsterile specimen and send it to the lab.

The client is preparing to obtain a clean-catch midstream urine specimen. List in order the steps needed to complete the diagnostic test.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into stool. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional

A client who is a paraplegic as a result of an auto accident has incontinence. The nurse correctly recognizes that which type of incontinence is most likely?

Reflex

Which urinary care teaching will the nurse provide to a young adult female client?

Refrain from douching unless ordered by a health care provider.

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?

Regular toileting routine

A nurse is performing a client's intermittent closed catheter irrigation and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's best response to this situation?

Repeat the irrigation. If the tubing was not clamped before introducing the irrigation solution, the nurse should repeat the irrigation. If the tubing is not clamped, the irrigation solution will drain into the urinary drainage bag and not enter the catheter. There is no immediate need to contact the primary care provider or to change the catheter.

The nurse is engaged in collecting a urine specimen for a routine urinalysis from a client with an indwelling catheter. What nursing action has the greatest impact on the accuracy of the testing results?

Selecting this particular specimen port site When it is necessary to collect a urine specimen from a client with an indwelling catheter, the specimen should be obtained from using the special port for specimens. This practice assures aspiration of fresh urine and helps assure result accuracy. A routine urinalysis requires at least 10 ml of urine; assuring a sufficient quantity of urine. Wearing gloves protects the nurse from any contact with the specimen. A client should be placed in position that supports comfort and modesty. While all actions are accurate, appropriately accessing the specimen port has the greatest impact on the accuracy of the urinalysis.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions?

The client should avoid wearing tight clothes or belts near the site.

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 asks the client to urinate before palpating the bladder. 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.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted?

The novice nurse selects an 18 French Foley catheter to insert

The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply.

The nurse gently palpates the client's symphysis pubis. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). The nurse adjusts the scanner head to center the bladder image on the crossbars.

The nurse is caring for a client with a Foley catheter in place who has a prescription for a sterile urine specimen for culture and sensitivity. The nurse implements which techniques to obtain the prescribed urine specimen? Select all that apply.

The nurse uses a syringe to withdraw urine from the port. The nurse dons clean gloves and cleanses the port with aseptic solution.

Which statements about suprapubic catheters is true?

They are often preferred over an indwelling urethral catheter for long-term urinary drainage.

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider?

Thrill and bruit The client is experiencing decreased circulation to the left arm that has an AV graft for hemodialysis. There is increased risk for the AV graft to clot and create a circulatory emergency. Obtaining a full set of vital signs would be indicated to evaluate overall status of the client; however, the health care provider would need to know if thrill and bruit are present over the AV graft. Absence of thrill and bruit is a medical emergency.

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action by the UAP is noted?

UAP positions the bedpan so the client's buttocks rest on the shallow end of the regular bedpan.

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply.

Urinary incontinence Difficulty voiding Urinary retention Burning or irritation while voiding

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?

Urine culture sensitivity - 100,000/mL

The nurse is preparing a client for an intravenous pyelogram. Which nursing actions are performed correctly? Select all that apply.

Withhold food or fluids 12 hours before testing. Give an enema the day of the examination. Obtain client's allergy history. Give a laxative the evening before the examination.

A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample?

a sample of urine that is considered sterile

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake.

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

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

A 57-year-old man is suffering from polyuria. What can cause polyuria?

diabetes insipidus 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.

The nurse is preparing to place a Foley catheter for a female client who will soon have surgery. Into what position will the nurse place the client?

dorsal recumbent

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning 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 reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate?

functional

The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing?

functional

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?

intermittent urethral catheter

Which assessment data, collected by the nurse, indicates that a client may have the nursing diagnosis of urge urinary incontinence? Select all that apply.

loses urine when a toilet is not readily available urinates 20 times in 24 hours experiences accidental loss of urine when there is an urgent need to urinate

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?

one or both of the ureters are surgically implanted elsewhere

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:

pus.

An older adult woman tells the nurse that she has trouble controlling her urine. She states, "The urine starts dripping even before I feel like I have to go." The nurse interprets this as:

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

A 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 risk for infection situational low self-esteem

The nurse is planning care for a client with a newly placed urostomy. For what priority problems will the nurse address and provide interventions? Select all that apply.

situational low self-esteem risk for infection

Which type of incontinence is caused by pelvic floor muscle weakness?

stress

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?

stress incontinence

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?

strongly aromatic, dark amber

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention

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." 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.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse is caring for a client who reports having cloudy, foul-smelling urine. Which assessment question should the nurse ask the client?

"Are you experiencing burning and frequency?"

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client?

"Are you taking any B-complex vitamins?"

The nurse is providing care for an older adult admitted to the hospital with urinary retention. The client asks the nurse, "What is wrong with me?" Which is the best response by the nurse?

"As men age, the prostate enlarges over time."

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?

"Having sexual relationships does not put a woman at risk for developing a UTI."

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."

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 use clean gloves to handle the catheter and other equipment."

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?

"Let's explore structuring activities and toileting breaks."

A woman informs the nurse that when she is experiencing stress it is difficult to void, and wonders why this happens. What is the nurse's best explanation?

"Stress causes the muscles to become tense."

The nurse has placed a urine collection bag on an infant. How often should the nurse check the bag to see if the infant has voided?

Every 15 minutes

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority?

Asking the client when he or she had last urinated In assessing the bladder, the nurse would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included?

Assist the client to a normal voiding position when possible.

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

What accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter?

Avoid irrigation unless needed to relieve an obstruction.

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.

Which is true regarding the normal urination?

Catheterized clients should drain a minimum of 30 mL of urine per hour.

A client could experience increased urination when using which classification of medication?

Cholinergic agents 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.

Urinalysis and urine culture testing have been ordered for a client who has an indwelling urinary catheter. The nurse observes that there is currently no urine in the client's catheter tube. What should the nurse do?

Clamp the tube below to access the port to allow urine to accumulate. If there is not sufficient urine for collection, the nurse should clamp the tubing below the access port for up to 30 minutes. Increased fluid intake will not cause urine to accumulate in the tubing. Similarly, repositioning is unlikely to resolve the problem. Aspirating from an air-filled catheter tube may draw a contaminated sample from tubing distal to the access port.

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

Contact the health care provider

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 the pubic muscles for 3 seconds, then relax.

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?

Fasten the condom securely enough to prevent leakage without constricting blood flow.

The nurse is caring for a client with a history of renal insufficiency and type 2 diabetes. Which prescription, if noted in the client's chart, would alert the nurse to discuss with the health care practitioner?

Gentamicin 70 mg intramuscular (IM) every 8 hours

The nurse is changing a stoma appliance on an ileal conduit. Which nursing action is recommended procedure? Select all that apply.

Gently remove the appliance, starting at the top and keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping as needed. Make sure skin around stoma is thoroughly dry by patting it dry.

The nurse has inserted a client's urinary catheter as ordered, but there has been no immediate flow of urine. What is the nurse's most appropriate action?

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

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?

Keep muscles contracted for at least 10 seconds. 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.

A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? Select all that apply.

Neuromuscular problems may interfere with voluntary control of urination. Diminished ability of kidneys to concentrate urine may result in nocturia. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. Decreased bladder contractility may lead to urine retention and stasis. Altered thought processes may cause urinary frequency.

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.

The nurse is collecting a clean-catch specimen from a client. Which nursing action is performed correctly in this procedure?

Position the container near the meatus, and collect at least 10 mL of urine.

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation?

Prime the tubing with the 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?

Reddened perineal skin

A nurse is caring for an older adult client who has been prescribed a condom catheter. What potential problems related to the use of a condom catheter should the nurse monitor in the client? Select all that apply.

Restricted blood flow to the glans tissue Excoriation of the skin in the glans area Kinks in tubing that encourage backflow of urine

The health care provider requests an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position?

Sims

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. Strict aseptic technique must be used when collecting and handling urine specimens. A clean-catch specimen of urine may be collected in midstream.

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?

Stress

The nurse is preparing to catheterize a client who is incontinent of urine following bladder surgery. What fact should the nurse keep in mind when performing catheterization?

The bladder normally is a sterile cavity.

The nurse has received an order to remove a client's indwelling urinary catheter. Which actions are appropriate when carrying out this order? Select all that apply.

The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe.

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 smells like ammonia. There is pus in the urine. The urine is cloudy.

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?

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted.

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.

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.

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

Which type of incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions?

urge

The nurse is educating a client with an ileal conduit about the effects of food and fluid intake on the amount and quality of urine produced by the body. Which teaching points should the nurse include? Select all that apply.

Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. Fluid overload leads to excretion of a large quantity of dilute urine. Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine.

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 a urologic stent

A nurse prepares a client with a recently created ileal conduit to be discharged from the hospital. Which is an expected assessment finding?

Mucus in the urine is a normal finding. 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 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?

Notifying the health care provider of the assessment findings

A nurse maintaining continuous bladder irrigation on a client notes that hourly drainage is less than amount of irrigation being given. Which interventions would be appropriate in this situation? Select all that apply.

Palpate for bladder distention. Check to make sure that the tubing is not kinked. If return flow remains decreased, notify the health care provider.

The nurse is preparing to assess a client's postvoid residual using a bladder scanner. Place the following steps in the correct order. Use all options.

Press the appropriate gender button. Position the scanner head with directional arrow pointing to the head. Press scanner head onto the skin 1 to 1.5 inches (2.5 to 3.75 cm) above the symphysis pubis. Aim the scanner head toward the coccyx and activate the scan. Verify that screen crossbars fall within the bladder image. Observe and record the volume measurement on the screen.

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.

Use of an indwelling urinary catheter leads to the loss of bladder tone.

True

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly?

Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe. 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.

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 confused client that requires a sterile urine specimen to be obtained a client with an enlarged prostate that is unable to void

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing:

oliguria.

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.

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?

"Let's review the types of fluids that your child drinks in the morning."

The nurse is caring for a postoperative client just returning from surgical insertion of a peritoneal dialysis catheter. Which are the nurse's priority assessments of the peritoneal dialysis catheter insertion site? Select all that apply.

Odor Bleeding Drainage Pain

The nurse has received an order to catheterize a female client. What action should the nurse perform?

Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm). The nurse should lubricate 1 to 2 in (2.5 to 5 cm) of the catheter tip and, using the dominant hand, hold the catheter 2 to 3 in (5 to 7.5 cm) from the tip and insert slowly into the urethra. The nurse should then advance the catheter until there is a return of urine (approximately 2 to 3 in [5 to 7.5 cm]) and, once urine drains, advance catheter another 2 to 3 in (5 to 7.5 cm). The nurse may encounter slight resistance when advancing the catheter, but this does not necessarily indicate correct placement; further advancement of the catheter may be necessary to obtain urine flow.

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.

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 two glasses of water before and after sexual intercourse.

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 is acutely confused and has been diagnosed with delirium. 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 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 dehydrated.

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?

The client will have to wear an external appliance to collect urine.

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

Urinal

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.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?

Wearing gloves when handling the urine

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. 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.

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

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

A client has been NPO. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color?

dark amber Urine may be dark amber or orange-brown if it is very concentrated secondary to a decreased fluid intake. Urine is lighter than normal if it is diluted. Foods or drugs can also alter the color of urine. Tea-colored or very dark urine is a sign of dehydration.

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy

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?

stress

The nurse is assessing a female client who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply?

"You are experiencing stress incontinence. Do you know how to do Kegel exercises?"

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?

blood

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should

deflate the balloon, insert the catheter further, and slowly attempt reinflation If the client reports pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the client's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 0.5 to 1 in (1.25 to 2.5 cm), and slowly attempt to inflate the balloon again. Re-attempting inflation in the same location or after slight withdrawal could cause trauma to the client's urethra. It is not necessary to utilize a smaller gauge catheter

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

An older adult client is experiencing urinary retention. What age-related physiologic change does the nurse discuss with the client that may be a contributing factor?

Older adults may have a decrease in contraction of the bladder.

A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs continuous bladder irrigation. Which intervention should the nurse perform when providing continuous bladder irrigation?

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

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.

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 the possibility that the client has urethral strictures 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.

The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment?

"Do you have the sensation to urinate?" In reflex incontinence, the client empties the bladder without the sensation of the need to void. The client dribbles with overflow incontinence. In total incontinence, the client has a continuous and unpredictable loss of urine. Stress incontinence occurs when there is an increase in the intra-abdominal movements, such as coughing and straining.

A nurse is performing a physical assessment of a client's urinary system. Which nursing actions are appropriate during this assessment? Select all that apply.

If using a bedside scanner, place the client in a supine position. Inspect the urethral orifice for any signs of inflammation, discharge, or foul odor. Retract the foreskin of an uncircumcised male client to visualize the meatus. The nurse assess the client's urine for color, odor, clarity, and the presence of any sediment.

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult?

Acute confusion

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

Check health record for provider's order.

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 device must be programmed for the biological sex of the client by pushing the correct button on the device. 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. 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.

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.

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 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.

A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours?

functional incontinence

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?

stress

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.

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