Competency 15: Nclex
When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? A. The client sets the drainage bag on the floor while sitting down. B. The client keeps the drainage bag below the bladder at all times C. The client clamps the catheter drainage tubing while visiting with the family D. The client loops the drainage tubing below its point of entry into the drainage bag
Correct Answer B To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because it could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.
Nurse Gil is aware that the following statements describing urinary incontinence in the elderly is true? A. Urinary incontinence is a normal part of aging B. Urinary incontinence isn't a disease C. Urinary incontinence in the elderly can't be treated D. Urinary incontinence is a disease
Correct Answer B Urinary incontinence isn't a normal part of aging nor is it a disease. It may be caused by confusion, dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients with urinary incontinence can be treated; some can be cured.
Nurse Pippy is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? A. Fluid intake should be double the urine output B. Fluid intake should be approximately equal to the urine output C. Fluid intake should be half the urine output D. Fluid intake should be inversely proportional to the urine output
Correct Answer B Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output.
A female client with an indwelling urinary catheter is suspected of having a urinary tract infection. Nurse Angel should collect a urine specimen for culture and sensitivity by: A. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container B. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle C. draining urine from the drainage bag into a sterile container D. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine
Correct Answer B Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. A. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. C. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. D. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect.
A client is frustrated and embarrassed by urinary incontinence. Which of the following measures should Nurse Ginny include in a bladder retraining program? A. Establishing a predetermined fluid intake pattern for the client B. Encouraging the client to increase the time between voidings C. Restricting fluid intake to reduce the need to void D. Assessing present elimination patterns
Correct Answer D The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.
A client in the hospital has an indwelling urinary catheter, and the nurse is instructing the nursing assistant in the appropriate care to provide. The nurse teaches the assistant to: A) Empty the drainage bag at least q8h B) Cleanse up the length of the catheter to the perineum C) Use clean technique to obtain a specimen for culture and sensitivity D) Place the drainage bag on the client's lap while transporting the client to testing
Correct Answer: A Empty the drainage bag at least q8h Explanation: The urinary drainage bag should be emptied at least every 8 hours. If large outputs are noted, more frequent emptying will be required. B. The perineum should be cleansed, and then down the catheter. C. Use sterile technique only to collect specimens from a closed drainage system. D. Avoid raising the drainage bag above the level of the bladder. The drainage bag can be attached to the wheelchair below the level of the client's bladder for transport. It should not be placed on the client's lap.
A 24 hour urine specimen collection is ordered. The test will need to be restarted if the following occurs: A) The client voids in the toilet B) The urine specimen is kept cold C) The first voided urine is discarded D) The preservative is placed in the collection container
Correct Answer: A) The client voids in the toilet Explanation: Missed specimens make the whole collection inaccurate. The test must be restarted. B. The urine specimen is kept in a collection container, which may contain preservatives, or the urine may be kept in a collection container on ice. The urine specimen being kept cold is not a reason to restart a timed urine collection. C. This is correct. The timed period begins after the client urinates. The first voided urine is discarded, and then the time for collection begins. D. The urine specimen is kept in a collection container, which may contain preservatives.
The nurse is caring for clients on a postoperative unit in the medical center. The nurse is alert to the possibility that for 24 to 48 hours of the postoperative period, clients may experience the following as a result of the anesthetic used during the surgery: A) Colitis (inflammation of the colon) B) Stomatitis (sore mouth) C) Paralytic ileus D) Gastrocolic reflex
Correct Answer: C) Paralytic ileus Explanation: Any surgery that involves direct manipulation of the bowel temporarily stops peristalsis. This condition, called paralytic ileus, usually lasts about 24 to 48 hours. A. Colitis is inflammation of the colon. It is not a result of anesthetic used during surgery. B. Stomatitis is inflammation of the mouth. It is not caused by anesthetic used during surgery. D. The gastrocolic reflex is the peristaltic wave in the colon induced by entrance of food into the stomach. It is not a result of anesthetic used during surgery.
The nurse is visiting the client who has a nursing diagnosis of "Alteration in urinary elimination; retention". On assessment, the nurse anticipates that this client will exhibit: A) Severe flank pain and hematuria B) Pain and burning on urination C) A loss of the urge to void D) A feeling of pressure and voiding of small amounts
Correct Answer: D) A feeling of pressure and voiding of small amounts Explanation: With urinary retention, urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the symphysis pubis, restlessness, and diaphoresis. The sphincter temporarily opens to allow a small volume of urine (25 to 60 ml) to escape, with no real relief of discomfort. A. Severe flank pain and hematuria are supporting data for an upper UTI (pyelonephritis). B. Pain and burning on urination are symptoms of a lower UTI (such as a bladder infection). C. Supportive data for reflex incontinence would include a loss of the urge to void.
The nurse recognizes that changes in elimination occur with the aging process. An expected change in bowel elimination is which of the following? A) Absorptive processes are increased in the intestinal mucosa B) Esophageal emptying time is increased C) Changes in nerve innervation and sensation cause diarrhea D) Chewing is less efficient
Correct Answer: D) Chewing is less efficient Explanation: An expected change in bowel elimination is decreased chewing and decreased salivation resulting in less efficient chewing. A. Decreased nutrient absorption of the small intestine occurs in the older adult. B. Esophageal emptying slows, as a result of reduced motility especially in the lower third, of the esophagus. C. With decreased peristalsis and weakened musculature, the older adult is more prone to constipation. Duller nerve sensations may place the older adult at increased risk for fecal incontinence.
Urinary elimination may be altered with different pathophysiologic conditions. For the client with diabetes mellitus, the nurse anticipates that an initial urinary sign or symptom will be: A) Urgency B) Dysuria C) Hematuria D) Polyuria
Correct Answer: D) Polyuria Explanation: An initial urinary symptom of diabetes mellitus is polyuria. A. Urgency is not a symptom of diabetes mellitus. Urgency may be caused by a full bladder, bladder irritation from infection, incompetent urethral sphincter, or psychological stress. B. Dysuria is not a symptom of diabetes mellitus. Dysuria may be caused by bladder inflammation, trauma, or inflammation of the urethral sphincter. C. Hematuria is not a symptom of diabetes mellitus. Hematuria may be a symptom of neoplasms of the bladder or kidney, glomerular disease, infection of the kidney or bladder, trauma to urinary structures, calculi, or bleeding disorders.
An assessment is completed by the nurse and a nursing diagnosis for the oriented adult female client is identified as "Stress incontinence related to decreased pelvic muscle tone". An appropriate nursing intervention based on this diagnosis is to: A) Apply adult diapers B) Catheterize the client C) Initiate a bladder emptying program D) Teach Kegel exercises
Correct Answer: D) Teach Kegel exercises Explanation: Pelvic floor exercises, also known as Kegel exercises, improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups. These exercises have demonstrated effectiveness in treating stress incontinence, overactive bladders, and mixed causes of urinary continence. A. The client is oriented and therefore could be taught Kegel exercises to improve pelvic floor muscle tone. Applying adult diapers does not improve the client's problem of incontinence and places the client at risk for skin breakdown. B. Because bladder catheterization carries the risk of urinary tract infection (UTI), it is preferable to rely on other measures for management of incontinence. The nurse can support the use of Kegel exercises as an inexpensive nonpharmacologic intervention to reduce the client's stress incontinence. C. The client's condition do not require this intervention at this time.
Nurse Karen is caring for a client who had a cerebrovascular accident (CVA). Which nursing intervention promotes urinary continence? A. Encouraging intake of at least 2 L of fluid daily B. Giving the client a glass of soda before bedtime C. Taking the client to the bathroom twice per day D. Consulting with a dietitian
Correct Answer A By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence.
The client asks the nurse to recommend bulk-forming foods that may be included in the diet. Which of the following should be recommended by the nurse? A) Whole grains B) Fruit juice C) Rare meats D) Milk products
Correct Answer: A) Whole grains Explanation: Bulk-forming foods, such as grains, fruits, and vegetables, absorb fluids and increase stool mass. B. Fruit juice is not a bulk-forming food. C. Rare meats are not bulk-forming foods. D. Milk products are not bulk-forming foods.
A 6-month-old infant has severe diarrhea. The major problem associated with severe diarrhea is: A) Pain in the abdominal area B) Electrolyte and fluid loss C) Presence of excessive flatus D) Irritation of the perineal and rectal area
Correct Answer: B) Electrolyte and fluid loss Explanation: Diarrhea can result in serious fluid and electrolyte or acid-base imbalances. Infants and older adults are particularly susceptible to associated complications. A. Pain from abdominal cramping may occur with diarrhea, but it is not the major problem associated with severe diarrhea. C. Excessive flatus is not the major problem associated with severe diarrhea. D. Because repeated passage of diarrhea stools exposes the skin of the perineum and buttocks to irritating intestinal contents, meticulous skin care and containment of fecal drainage is needed to prevent skin breakdown. Skin care is important but it is not the major problem.
A client with an excessive alcohol intake has a reduced amount of antidiuretic hormone (ADH). The nurse anticipates the client will exhibit: A) Hematuria B) An increased blood pressure C) Dry mucous membranes D) A low serum sodium level
Correct Answer: C) Dry mucous membranes Explanation: Alcohol inhibits the release of antidiuretic hormone (ADH), resulting in increased water loss in urine. The client may show signs of decreased fluid volume (dehydration), including dry mucous membranes. A. The effects of excessive alcohol intake and reduced ADH will not cause hematuria. B. Having decreased antidiuretic hormone will lead to increased urine production. The client may exhibit a decreased blood pressure because of decreased fluid volume. D. Having decreased ADH will lead to increased urine production. The client may exhibit an increased serum sodium level with dehydration.
