Fundamental Chapter 37: Urinary Elimination
A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client? A) "How frequently do you urinate each day?" B) "Are you on any type of special diet at home?" C) "How often do you have a bowel movement?" D) "Are you on any blood pressure medications?"
A) "How frequently do you urinate each day?" Explanation: The client with frequent urinary tract infections may have infrequent urination, which can lead to stagnation of urine in the bladder; this potentially leads to growth of bacteria and a UTI. Taking blood pressure medication, being on a special diet, or having bowel movements do not increase the risk for urinary tract infections.
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? A) "Stress causes the muscles to become tense." B) "You require greater privacy to void." C) "You might have a neurologic condition." D) "What medications are you taking?"
A) "Stress causes the muscles to become tense." Explanation: A person's muscles may become so tense that relaxation of the perineal muscles does not occur, and voiding is inhibited.
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? A) 24-hour specimen B) clean-catch specimen C) random specimen D) intermittent specimen
A) 24-hour specimen Explanation: A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? A) Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. B) Administer an IV on the arm high above the access site. C) Perform venipuncture below the access site to obtain a blood sample for laboratory testing. D) Measure the client's blood pressure on the arm above the access site.
A) Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Explanation: The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.
Which symptom will have a great impact on the extracellular fluid for water conservation? A) Burns B) Fracture C) Small laceration D) Pain
A) Burns Explanation: The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.
Which is true regarding the normal urination? A) Catheterized clients should drain a minimum of 30 mL of urine per hour. B) In adults, the average amount of urine per void is 500 mL. C) Urinary output does not vary all that much between adults and children. D) In adults, the amount of urine voided typically does not depend on fluid intake and losses.
A) Catheterized clients should drain a minimum of 30 mL of urine per hour. Explanation: Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.
A client could experience increased urination when using which classification of medication? A) Cholinergic agents B) Analgesic medications C) Central nervous system depressants D) Stool softeners
A) Cholinergic agents Explanation: Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination. Analgesics act to relieve pain. Central nervous system depressants are medicines that include sedatives, tranquilizers, and hypnotics. These drugs can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders. Stool softeners makes bowel movements softer and easier to pass.
Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. A) Contact the health care provider to ask for an order for catheter discontinuation. B) Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). C) Perform, or allow client to perform, perineal hygiene at least once daily. D) Ensure that the drainage bag is above the level of the bladder at all times. E) Discontinue to catheter and report this to the healthcare provider.
A) Contact the health care provider to ask for an order for catheter discontinuation. C) Perform, or allow client to perform, perineal hygiene at least once daily. Explanation: The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.
The nurse is changing a stoma appliance on an ileal conduit. Which nursing action is recommended procedure? Select all that apply. A) Gently remove the appliance, starting at the top and keeping the abdominal skin taut. B) Remove appliance faceplate by pulling appliance from skin rather than pushing. C) Apply a silicone-based adhesive remover by spraying or wiping as needed. D) Clean skin around stoma with alcohol on a gauze pad. E) Make sure skin around stoma is thoroughly dry by patting it dry. F) Apply faceplate by using firm, even pressure for approximately 60 seconds.
A) Gently remove the appliance, starting at the top and keeping the abdominal skin taut. C) Apply a silicone-based adhesive remover by spraying or wiping as needed. E) Make sure skin around stoma is thoroughly dry by patting it dry. Explanation: The nurse would gently remove the appliance, starting at the top and keeping the abdominal skin taut. This method would prevent excessive damage to skin and tissue of the client. The nurse would apply a silicone-based adhesive remover by spraying or wiping as needed. The adhesive remover helps to prevent skin and tissue damage. The nurse would make sure skin around the stoma is thoroughly dry by patting it dry. Moist skin does not hold adhesives well, possibly causing skin and tissue damage. The nurse would not remove the appliance faceplate by pulling the appliance from the skin rather than pushing. The nurse would not clean the skin around the stoma with alcohol. Alcohol is drying to the skin, possibly causing skin or tissue damage. The nurse would not hold the faceplate firmly in place for 60 seconds when placing it. Pressure for 30 seconds is sufficient.
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? A) Have the client take a deep breath to relax the perineal and abdominal muscles. B) Advance the catheter slightly, because a drainage hole may be resting against the bladder wall. C) Lower the head of the client's bed to increase pressure in the bladder area. D) Leave the catheter in place and reassess in 30 minutes.
A) Have the client take a deep breath to relax the perineal and abdominal muscles. Explanation: 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.
What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? A) It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. B) The client can apply it himself with minimal supervision. C) It can be left in place for a long period of time. D) A sterile urine specimen can be obtained from the drainage bag tubing.
A) It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. Explanation: The external condom catheter is not in the bladder. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters which are placed in the bladder. Because it is not sterile, a sterile urine specimen cannot be obtained. Often, the client does not place the external condom catheter by himself. The catheter is changed every day and the skin of the penis is assessed.
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? A) Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. B) Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. C) Ask the client to bear down until the catheter is expelled. D) Remove the catheter from the vagina and attempt to insert it into the bladder.
A) Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Explanation: Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.
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? A) Position the client in a supine position. B) Administer a diuretic, as ordered. C) Have the client rest for 15 minutes before the assessment. D) Assess the client's need for analgesia.
A) Position the client in a supine position. Explanation: Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? A) The client has an enlarged prostate. B) The diameter of the catheter is too large. C) The nurse failed to deflate the retention balloon after pretesting it for integrity. D) The client has an occult abscess in the urethra.
A) The client has an enlarged prostate. Explanation: Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.
A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. Which information is essential for the nurse to review with the client as a strategy to decrease future risk of UTI? A) Voiding before and after sexual intercourse B) Wiping the perineal area from the rectal area to the urethra C) Taking baths instead of showers D) Wearing satin or silk underwear that hugs the skin tightly
A) Voiding before and after sexual intercourse Explanation: Measures to decrease the risk for a UTI include drinking ten 8-ounce glasses of water daily; observing for signs and symptoms of a UTI; drying the perineal from the urethra toward the rectum; voiding before and after sexual intercourse; showering rather than bathing; wearing cotton underwear; avoiding tight, constricting clothing; and drinking cranberry or blueberry juice daily.
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? A) Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. B) Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. C) Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. D) Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic.
A) Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. Explanation: When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens and aseptic technique. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.
A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter? A) a flexible sheath that is rolled around the penis B) a bag attached by adhesive backing to the skin around the genitals C) a urine drainage tube inserted but not left in place D) a urine drainage tube that is left in place over a period of time
A) a flexible sheath that is rolled around the penis Explanation: A condom catheter is a flexible sheath that is rolled around the penis. A urinary bag (U-bag) is a bag attached by adhesive backing to the skin surrounding the genitals. A straight catheter is a urine drainage tube inserted but not left in place. A retention (or indwelling) catheter is a urine drainage tube that is left in place over a period of time.
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? A) antihypertensive B) nonsteroidal anti-inflammatory drug (NSAID) C) H2-receptor antagonist D) calcium supplement
A) antihypertensive Explanation: The nurse wants to determine if the timing of the urinary incontinence correlates with the start of a medication that could promote urinary incontinence. Antihypertensives may increase urinary incontinence, because they cause more fluid to enter into the vascular system. Thus, the fluid would be excreted through the urinary system. The other medication classifications listed do not have urinary incontinence as an adverse reaction.
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? A) anuria B) oliguria C) nocturia D) urinary retention
A) anuria Explanation: Absence of urine for a 24-hour period reflects anuria.
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? A) cloudy, foul odor B) light yellow, clear C) clear, dark amber D) strongly aromatic, amber
A) cloudy, foul odor Explanation: The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine. Urine is normally light yellow and clear. Dark amber urine that is strongly aromatic could indicate dehydration, but would not create the symptoms noted.
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: A) deflate the balloon, insert the catheter further, and slowly attempt reinflation. B) wait for 30 seconds, help the client to relax, and attempt inflation again. C) stop, deflate the balloon, withdraw the catheter 0.75 to 1.5 in (2 to 4 cm), and slowly reinflate. D) deflate the balloon, withdraw the catheter, and use a smaller sized catheter.
A) deflate the balloon, insert the catheter further, and slowly attempt reinflation. Explanation: 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.
A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record? A) greater than normal urinary volume B) inadequate elimination of urine C) absence of urine D) difficult or uncomfortable voiding
A) greater than normal urinary volume Explanation: Polyuria means greater than normal urinary elimination. It may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects (e.g., coffee, tea), or taking certain medications actually can increase urination. Oliguria is inadequate elimination of urine. Anuria means the absence of urine. Dysuria is difficult or uncomfortable voiding.
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. A) risk for impaired skin integrity B) stress urinary incontinence C) risk for infection D) situational low self-esteem D) functional urinary incontinence
A) risk for impaired skin integrity C) risk for infection D) situational low self-esteem Explanation: The client with a new urostomy may be at risk for impaired skin integrity and infection if the client does not care properly for the ostomy. Therefore, the nurse will use these nursing diagnoses to plan care and education. The client may also experience a change in self-esteem due to this different way of elimination. The client will not experience types of incontinence, since the urostomy will continually drain urine.
A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide? A) Collect the first urine expelled. B) After the initial stream is initiated, collect the sample. C) Wait until the void is almost over to collect a specimen. D) Collect the entire urinary output.
B) After the initial stream is initiated, collect the sample. Explanation: A clean-catch specimen is collected in mid-stream. It is not reasonable, nor necessary, to collect the entire urinary output. It is not correct to collect the first urine expelled or to wait until the void is almost over.
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? A) Incontinence after the age of 3 years is not normal. B) Boys may take longer for daytime continence than girls. C) Boys may walk by 1 year and should be continent by 3 years. D) Daytime continence is usually not achieved by boys until age 5.
B) Boys may take longer for daytime continence than girls. Explanation: Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.
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? A) Loosen the internal muscles used to prevent or interrupt urination. B) Keep muscles contracted for at least 10 seconds. C) Relax muscles for at least 5 minutes between Kegels. D) Perform these exercises two times daily for a week.
B) Keep muscles contracted for at least 10 seconds. Explanation: 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 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? A) The client is on a low protein diet. B) The client is dehydrated. C) The client has a history of osteoarthritis. D) The client is lactose intolerant.
B) The client is dehydrated. Explanation: The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.
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? A) Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. B) Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. C) Perform hand hygiene between cleansing the woman's labia and inserting the catheter. D) Insert the catheter with her left hand while supporting the woman with her right hand.
B) Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Explanation: Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.
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? A) Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container. B) Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. C) Obtained urine specimen from urinary drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port. D) Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure.
B) Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. Explanation: The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.
The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend? A) fracture pan B) bedside commode C) bedpan D) regular bathroom
B) bedside commode Explanation: The client with weakness who tires easily may benefit from a bedside commode. Because the client is ambulatory, a bedpan or fracture pan is not needed. Ambulating to the regular bathroom may increase the risk for falls.
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? A) supine B) dorsal recumbent C) lithotomy D) semi-Fowler's
B) dorsal recumbent Explanation: The appropriate position for a female client who will have a Foley catheter placed is the dorsal recumbent position. Other answers are incorrect.
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? A) indwelling urethral catheter B) intermittent urethral catheter C) Foley catheter D) retention catheter
B) intermittent urethral catheter Explanation: An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted.
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? A) "I will place a bath blanket over the client to provide privacy." B) "The client will be placed in a reclining position with knees bent." C) "I will use clean gloves to handle the catheter and other equipment." D) "Washing hands before and after the procedure is important."
C) "I will use clean gloves to handle the catheter and other equipment." Explanation: Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse.
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. A) Dry the perineal area after urination or defecation from the back to the front. B) Take baths instead of showers. C) Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. D) Wear underwear with a cotton crotch. E) Avoid clothing that is tight and restrictive on the lower half of the body.
C) Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. D) Wear underwear with a cotton crotch. E) Avoid clothing that is tight and restrictive on the lower half of the body. Explanation: Client education can help prevent UTI recurrence. Teaching the client about measures that promote health and decrease the severity and incidence of UTIs is a major nursing responsibility. The nurse should instruct the client to drink eight to ten 8-oz glasses (1,920 to 2,400 mL) of water daily, drink two 8-oz glasses (480 mL) of water before and after sexual intercourse, void immediately after sexual intercourse, wear underwear with a cotton crotch, and avoid clothing that is tight and restrictive on the lower half of the body. Instruction should include drying the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum, as well as taking showers instead of baths.
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? A) Checking for blood return in the CVC B) Placing the client as N.P.O. status C) Notifying the health care provider of the assessment findings D) Obtaining laboratory studies
C) Notifying the health care provider of the assessment findings Explanation: The assessment is indicative of hospital-acquired catheter infection associated with the CVC. The medical provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Checking for blood return is not indicated and access to the CVC used for hemodialysis should not be attempted without a prescription to do so from the health care provider.
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? A) This urinary diversion is only temporary. B) The client will need to change the urinary pouch every 4 hours. C) The client will have to wear an external appliance to collect urine. D) Urination can be voluntarily controlled after the stoma heals from the initial surgery.
C) The client will have to wear an external appliance to collect urine. Explanation: An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.
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? A) reddish-brown, clear B) clear, light yellow C) dark brown, cloudy D) aromatic, green
C) dark brown, cloudy Explanation: The client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine. Other answers are incorrect.
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? A) urge B) reflect C) stress D) total
C) stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Other types of incontinence have different causative factors.
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? A) "It would be best just to get some adult diapers." B) "Let me refer you to a urologist who can help you." C) "Don't worry, this is a normal condition for older adults." D) "Let's explore structuring activities and toileting breaks."
D) "Let's explore structuring activities and toileting breaks." Explanation: The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.
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? A) "This is extremely abnormal. You will need to see your son's pediatrician." B) "I would only worry about this if you were raising a daughter." C) "It would be appropriate to place your son in incontinence undergarments." D) "Let's review the types of fluids that your child drinks in the morning."
D) "Let's review the types of fluids that your child drinks in the morning." Explanation: Bladder irritants such as caffeine can cause urge incontinence; it is appropriate to determine whether the child is consuming fluids that contain caffeine. The child's urge incontinence is not extremely abnormal, and this physiological response is not related to gender. It is too soon to refer the client to the health care provider without taking a history, and it is impractical to simply recommend incontinence undergarments.
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? A) Contract abdominal muscles 10 times per day. B) Squat down and then jump up to a standing position. C) Lie on the floor, raise, then lower your legs 20 times per day. D) Contract the pubic muscles for 3 seconds, then relax.
D) Contract the pubic muscles for 3 seconds, then relax. Explanation: Pelvic floor exercises, or Kegel exercises, strengthen the pubococcygeal muscles and effectively promote urinary control. The nurse should inform the women to locate the muscles used to start and stop urinating. Then contract those muscles and relax them repeatedly. Strengthening the abdominal muscles will not help with urinary control. Squatting, jumping, and performing leg lifts will help to strengthen the quadriceps and hamstrings.
A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? A) Placing the client as N.P.O. status. B) Obtaining laboratory studies. C) Sitting the client up in a greater than a 40-degree angle. D) Notifying the health care provider of the assessment findings.
D) Notifying the health care provider of the assessment findings. Explanation: The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter. The health care provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Sitting the client up may aggravate the pain. The nurse should attempt to keep the client in the most comfortable position possible until a prescription is received from the health care provider.
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? A) Encouraging the client to stay close to home B) Fluid restriction C) Indwelling catheterization D) Regular toileting routine
D) Regular toileting routine Explanation: The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.
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? A) The client drinks eight 8-oz glasses of cranberry juice daily. B) The client soaks in the bathtub daily for perineal care. C) Since the client is symptom-free, she no longer takes the prescribed antibiotics. D) The client drinks two glasses of water before and after sexual intercourse.
D) The client drinks two glasses of water before and after sexual intercourse. Explanation: Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.
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? A) The client may bathe rather than shower, provided the site is covered with gauze. B) A dressing should always be worn over the site to avoid leaking. C) Sterile technique must be observed by the client in the home setting. D) The client should avoid wearing tight clothes or belts near the site.
D) The client should avoid wearing tight clothes or belts near the site. Explanation: Clients should avoid baths and public pools as well as wearing tight clothes and belts around the exit site. Once the site is healed, some health care providers do not require clients to wear a dressing unless the site is leaking. Clean technique is sometimes allowed in the home.
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. A) The nurse allows the urine to flow from the collection bag into the specimen container. B) The nurse disconnects the catheter and allows the urine to drip into the specimen container. C) The nurse clamps the tube below the access port for 40 minutes to allow urine to accumulate. D) The nurse uses a syringe to withdraw urine from the port. E) The nurse dons clean gloves and cleanses the port with aseptic solution.
D) The nurse uses a syringe to withdraw urine from the port. E) The nurse dons clean gloves and cleanses the port with aseptic solution. Explanation: When collecting a sterile urine specimen from a Foley catheter, the nurse wears clean gloves, cleans the port with an aseptic solution, and withdraws the specimen from the port with a syringe. The specimen should not be taken from the collecting bag because it may not be fresh and could result in an inaccurate analysis. The catheter should not be disconnected in order to prevent bacteria from entering the urinary system. If urine is not present in the tube, the tube may be clamped, but not to exceed 30 minutes.
The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice? A) Specimen hat B) Large urine collection bag C) Bedpan D) Urinal
D) Urinal Explanation: A urinal is the best choice to collect urine from a nonambulatory male client. If the client is on strict bed rest or confined to bed due to weakness or disability. the client must be positioned in bed in as close to an upright position as feasible. In most instances, the client is able to place and hold the urinal himself. If he is unable to do so, the nurse should hold the urinal in place while the client urinates or place the urinal and leave the client alone for a few moments. A bedpan is not the best choice for a male client who tend to prefer the bottle-like shape of the urinal, although female clients tend to prefer the shape of a bedpan. A specimen hat is for a commode. A large urine collection bag would be used with an indwelling catheter.
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? A) dehydration B) infection C) stasis D) blood
D) blood Explanation: A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? A) before bedtime B) afternoon C) evening D) first thing in the morning
D) first thing in the morning Explanation: While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.
A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? A) loss of small amount of urine when intra-abdominal pressure rises B) need to void is perceived frequently, with short-lived ability to sustain control of flow C) loss of urine control because a toilet is not accessible D) loss of urine without any identifiable pattern or warning
D) loss of urine without any identifiable pattern or warning Explanation: The nurse could describe the client's condition as the loss of urine without any identifiable pattern or warning. Stress incontinence can be described as loss of a small amount of urine when intra-abdominal pressure rises. Urge incontinence can be described as the need to void being perceived frequently with a short-lived ability to sustain control of flow. Functional urinary incontinence can be described as the loss of control over urination because a toilet is not accessible.
A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a: A) cystocele. B) enuresis. C) overactive bladder. D) neurogenic bladder.
D) neurogenic bladder. Explanation: Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both.
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? A) inability to control either urinary or bowel elimination B) hygiene measures used to keep meatus and adjacent area of the catheter clean C) use of a catheter to collect urine in a sterile environment D) one or both of the ureters are surgically implanted elsewhere
D) one or both of the ureters are surgically implanted elsewhere Explanation: The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.
Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? A) Foley catheter B) suprapubic catheter C) indwelling urethral catheter D) straight catheter
D) straight catheter Explanation: Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. A suprapubic catheter is used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area.
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? A) urge B) total C) reflex D) stress
D) stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.
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? A) cloudy, foul odor B) light yellow, clear C) clear, colorless D) strongly aromatic, dark amber
D) strongly aromatic, dark amber Explanation: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.
Use of an indwelling urinary catheter leads to the loss of bladder tone. True False
True Explanation: People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.