Chapter 55: Management of Patients with Urinary Disorders

12. A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patient's urine output hourly and notifies the physician when the hourly output is less than what?

A) 30 mL (A urine output below 30 mL/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.)

22. The nurse is assessing a patient admitted with renal stones. During the admission assessment, what parameters would be priorities for the nurse to address? Select all that apply.

A) Dietary history B) Family history of renal stones C) Medication history (Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the patient to stone formation.)

21. A patient is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what?

A) Hydronephrosis (If voiding dysfunction goes undetected and untreated, the upper urinary system may become compromised. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction, causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis.)

9. The nurse and urologist have both been unsuccessful in catheterizing a patient with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the physician using to drain the patient's bladder?

A) Insertion of a suprapubic catheter (When the patient cannot void, catheterization is used to prevent overdistention of the bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may be necessary, but would not be undertaken for the sole purpose of relieving a urethral obstruction. Delaying by applying compresses or administering medications could result in harm.)

39. The nurse has tested the pH of urine from a patient's newly created ileal conduit and obtained a result of 6.8. What is the nurse's best response to this assessment finding?

A) Obtain an order to increase the patient's dose of ascorbic acid. (Because severe alkaline encrustation can accumulate rapidly around the stoma, the urine pH is kept BELOW 6.5 by administration of ascorbic acid by mouth. An increased pH may suggest a need to increase ascorbic acid dosing.)

5. The nurse on a urology unit is working with a patient who has been diagnosed with oxalate renal calculi. When planning this patient's health education, what nutritional guidelines should the nurse provide?

A) Restrict protein intake as ordered. (Protein is restricted to 60 grams per day, while sodium is restricted to 3 to 4 grams per day. Low-calcium diets are generally NOT recommended except for true absorptive hypercalciuria. The patient should avoid intake of oxalate-containing foods and there is NO need to increase potassium intake.)

37. The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer?

A) Smoking cessation (People who smoke develop bladder cancer twice as often as those who do not smoke. High alcohol intake and low vitamin intake are not noted to contribute to bladder cancer.)

19. A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patient's post-procedure care?

A) Strain the patient's urine following the procedure. (Following ESWL, the nurse should strain the patient's urine for gravel or sand. There is no need to administer an I.V bolus after the procedure and there is NOT a heightened risk of fluid overload. Catheter insertion is NOT normally indicated following ESWL.)

2. A 42-year-old woman comes to the clinic complaining of occasional urinary incontinence when she sneezes. The clinic nurse should recognize what type of incontinence?

A) Stress incontinence (Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sudden increase in intra-abdominal pressure. Reflex incontinence is loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations usually associated with voiding. Overflow incontinence is an involuntary urine loss associated with overdistension of the bladder. Functional incontinence refers to those instances in which the function of the lower urinary tract is intact, but other factors [outside the urinary system] make it difficult or impossible for the patient to reach the toilet in time for voiding)

18. The nurse is working with a patient who has been experiencing episodes of urinary retention. What assessment finding would suggest that the patient is experiencing retention?

A) The patient's suprapubic region is dull on percussion. (Dullness on percussion of the suprapubic region is suggestive of urinary retention..)

25. A female patient has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the patient, the nurse should address what topic?

A) The risk of developing a vaginal yeast infection as a consequent of antibiotic therapy (Yeast vaginitis occurs in as many as 25% of patients treated with antimicrobial agents that affect vaginal flora. Yeast vaginitis can cause more symptoms and be more difficult and costly to treat than the original UTI.)

11. The nurse is caring for a patient recently diagnosed with renal calculi. The nurse should instruct the patient to increase fluid intake to a level where the patient produces at least how much urine each day?

B) 2,000 mL (Unless contraindicated by renal failure or hydronephrosis, patients with renal stones should drink at least eight 8-ounce glasses of water daily or have I.V fluids prescribed to keep the urine dilute. A urine output exceeding 2 L a day is advisable.)

32. A nurse on a busy medical unit provides care for many patients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which patient?

B) A patient who has Alzheimer's disease and who is acutely agitated (Patients who are confused and agitated risk trauma through the removal of an indwelling catheter which has the balloon still inflated.)

10. The nurse has implemented a bladder retraining program for an older adult patient. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurse's best response to this finding?

B) Avoid further interventions at this time, as this is an acceptable finding. (In adults older than 60 years of age, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Consequently, further interventions are not likely warranted.)

4. A 52-year-old patient is scheduled to undergo ileal conduit surgery. When planning this patient's discharge education, what is the most plausible nursing diagnosis that the nurse should address?

B) Deficient knowledge related to care of the ileal conduit (The patient will most likely require extensive teaching about the care and maintenance of a new urinary diversion. A diversion does not create a serious risk of fluid volume deficit. Mobility is unlikely to be impaired after the immediate postsurgical recovery. The sacral plexus is not threatened by the creation of a urinary diversion.)

42. A patient has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of disturbed body image. How can the nurse best address the effects of this urinary diversion on the patient's body image?

B) Encourage the patient to speak openly and frankly about the diversion. (Allowing the patient to express concerns and anxious feelings can help with body image, especially in adjusting to the changes in toileting habits. The nurse may have to initiate dialogue about the management of the diversion, especially if the patient is hesitant.)

38. Resection of a patient's bladder tumor has been incomplete and the patient is preparing for the administration of the first ordered instillation of topical chemotherapy. When preparing the patient, the nurse should emphasize the need to do which of the following?

B) Hold the solution in the bladder for 2 hours before voiding. (The patient is allowed to eat and drink before the instillation procedure. Once the bladder is full, the patient must retain the intravesical solution for 2 hours before voiding. The solution is instilled through the meatus; it is NOT consumed orally. There is no need to avoid acidic foods and beverages during treatment.)

35. A patient has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the patient's discharge education accordingly. What preventative measure should the nurse encourage the patient to adopt?

B) Increasing fluid intake (Increased fluid intake is encouraged to prevent the recurrence of kidney stones. Protein intake from all sources should be limited. Most patients do not require a low-calcium diet, but increased calcium intake would be contraindicated for all patients)

23. A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?

B) Limit the use of indwelling urinary catheters. (When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adult's risk of developing a UTI.)

30. A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patient's plan of care?

B) Risk for infection related to presence of an indwelling urinary catheter (Catheters create a high risk for UTIs. Because of this acute physiologic threat, the patient's risk for infection is usually prioritized over functional and psychosocial diagnoses.)

8. The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?

B) Teach the patient to perform pelvic floor muscle exercises. (Pelvic floor muscle exercises [sometimes called Kegel exercises] represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence. None of the other listed interventions has a behavioral approach.)

14. The nurse is teaching a health class about UTIs to a group of older adults. What characteristic of UTIs should the nurse cite?

B) The prevalence of UTIs in men older than 50 years of age approaches that of women in the same age group. (The antibacterial activity of the prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging. The prevalence of infection in men older than 50 years of age approaches that of women in the same age group. Men are NOT more likely to be asymptomatic and are NOT known to be reluctant to report UTIs.)

3. A nurse is caring for a female patient whose urinary retention has not responded to conservative treatment. When educating this patient about self-catheterization, the nurse should encourage what practice?

B) Using clean technique at home to catheterize (The patient may use a "clean" [nonsterile] technique at home, where the risk of cross-contamination is reduced. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. The female patient assumes a Fowler's position and uses a mirror to help locate the urinary meatus. The nurse teaches her to catheterize herself by inserting a catheter 7.5 cm into the urethra, in a downward and backward direction.)

28. A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment?

C) Arrange for biofeedback when the patient is learning to perform the exercises. (Research shows that written or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted pelvic muscle exercise [PME] uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME.)

1. A female patient has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this patient?

C) Drink liberal amounts of fluids. (The patient is encouraged to drink liberal amounts of fluids [water is the best choice] to increase urine production and flow, which flushes the bacteria from the urinary tract. •Frequent voiding [every 2 to 3 hours] is encouraged to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. •The patient should be encouraged to shower rather than bathe.)

13. The nurse is caring for a patient with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a patient with an indwelling catheter?

C) Empty the drainage bag at least every 8 hours. (To reduce the risk of bacterial proliferation, the nurse should empty the collection bag at least every 8 hours through the drainage spout, and more frequently if there is a large volume of urine.)

33. A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patient's admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply.

C) Hematuria D) Urinary frequency E) Acute pain (Stones lodged in the ureter [ureteral obstruction] cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic.)

31. A patient has had her indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the patient informs the nurse that she is experiencing urinary urgency resulting in several small-volume voids. What is the nurse's best response?

C) Inform the patient that this is not unexpected in the short term and scan the patient's bladder following each void. (Immediately after the indwelling catheter is removed, the patient is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the patient is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner; if the bladder has not emptied completely, straight catheterization may be performed. An indwelling catheter would NOT be reinserted to resolve the problem and diuretics would not be beneficial. Ongoing incontinence is NOT an expected finding after catheter removal.)

20. The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response?

C) Inform the primary care provider that the vascular supply may be compromised. (A healthy stoma is pink or red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised. A loose ostomy appliance and infections do not cause a dark purplish stoma.)

6. The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. What instruction should the nurse give the patient?

C) Notify the physician about cloudy or foul-smelling urine. (The patient should report the presence of foul-smelling or cloudy urine since this is suggestive of a UTI. Unless contraindicated, the patient should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand like debris is normal due to residual stone products. Hematuria is common after lithotripsy.)

34. A patient with a recent history of nephrolithiasis has presented to the ED. After determining that the patient's cardiopulmonary status is stable, what aspect of care should the nurse prioritize?

C) Pain management (The patient with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the patient's need for I.V fluids or for catheterization.)

36. A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of 101.1ºF (38.4ºC). How should the nurse best respond to the patient?

C) Tell the patient to report to the ED for further assessment. (Following ESWL, the development of a fever is abnormal and is suggestive of a UTI; prompt medical assessment and treatment are warranted. It would be inappropriate to delay further treatment.)

15. A patient has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed?

C) The widest part of the stoma (The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be NO more than 1.6 mm [1/8 inch] larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.)

41. The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices?

D) Avoid using moisturizing soaps and body washes when cleaning the peristomal area. (The patient is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the collection bag should NOT be allowed to become more than 1/3 full.)

29. A patient has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this patient's high risk for urinary retention and should implement what intervention in the patient's plan of care?

D) Double voiding (To enhance emptying of a flaccid bladder, the patient may be taught to double void. After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction and massage are similarly ineffective.)

26. An adult patient has been hospitalized with pyelonephritis. The nurse's review of the patient's intake and output records reveals that the patient has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding?

D) Encourage the patient to continue this pattern of fluid intake. (Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. No need to supplement this fluid intake with additional calories or sodium.)

16. A patient being treated in the hospital has been experiencing occasional urinary retention. What nursing action should the nurse take to encourage a patient who is having difficulty voiding?

D) Provide privacy for the patient. (Nursing measures to encourage normal voiding patterns include providing privacy, ensuring an environment and body position conducive to voiding, and assisting the patient with the use of the bathroom or bedside commode, rather than a bedpan, to provide a more natural setting for voiding. Most people find supine positioning not conducive to voiding.)

40. A patient is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The patient is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurse's most appropriate response?

D) Reassure the patient that this is an expected phenomenon. (Because mucous membrane is used in forming the conduit, the patient may excrete a large amount of mucus mixed with urine. This causes anxiety in many patients. To help relieve this anxiety, the nurse reassures the patient that this is a normal occurrence after an ileal conduit procedure. Urine testing for culture or pH is not required.)

27. An older adult has experienced a new onset of urinary incontinence and family members identify this problem as being unprecedented. When assessing the patient for factors that may have contributed to incontinence, the nurse should prioritize what assessment?

D) Reviewing the patient's medication administration record for recent changes (Many medications affect urinary continence in addition to causing other unwanted or unexpected effects. Stress and dietary changes could potentially affect the patient's continence, but medications are more frequently causative of incontinence. UTIs can cause incontinence, but these infections do not result from contact with infected individuals.)

24. A gerontologic nurse is assessing a patient who has numerous comorbid health problems. What assessment findings should prompt the nurse to suspect a UTI? Select all that apply.

D) Uncharacteristic fatigue E) New onset of confusion (The most common subjective presenting symptom of UTI in older adults is generalized fatigue. The most common objective finding is a change in cognitive functioning.)

17. A nurse's colleague has applied an incontinence pad to an older adult patient who has experienced occasional episodes of functional incontinence. What principle should guide the nurse's management of urinary incontinence in older adults?

D) Urinary incontinence is not considered a normal consequence of aging. (Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. Diuretics cannot always be safely discontinued. Fluid restriction and catheterization are not considered to be safe, first-line interventions for the treatment of incontinence.)

7. A female patient's most recent urinalysis results are suggestive of bacteriuria. When assessing this patient, the nurse's data analysis should be informed by what principle?

D) Urine samples are frequently contaminated by bacteria normally present in the urethral area. (Because urine samples [especially in women] are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies per mL of clean-catch, midstream urine is the measure that distinguishes true bacteriuria from contamination. A diagnosis does NOT require three consecutive positive results and urine does NOT contain a normal flora in the absence of a UTI. Most UTIs have a bacterial etiology.)