Funds Exam 5

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The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because

Escherichia coli pathogens are transmitted during surgical or catheterization procedures.

A nurse caring for a patient's hemodialysis access documents the following: "5/10/15 0930 Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider?

Area is warm to touch and edematous. Rationale: The nurse would report a site that is warm and edematous as this could be a sign of a site infection. The thrill and bruit are normal findings caused by arterial blood flowing into the vein. If these are not present, the access may be cutting off. No report of pain is a normal finding.

The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.)

Asking the patient to void and to discard the first sample. Keeping the urine collection container on ice.

A nurse is caring for a patient with a condom catheter. Which nursing actions are important? (Select All That Apply)

Avoiding kinks in the collection tubing Ensuring that the adhesive band is snug, not tight Leaving one inch between the glans penis and drainage tubing

Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective?

Recording an output that is larger than the amount instilled

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find

Reddened irritated skin on the buttocks.

A confused patient is incontinent of urine and stool and smears the stool on the bed linens and bed rails. Which should be the initial patient goal?

The patient will be clean and dry continuously.

A patient is admitted to the emergency department because of hypertension and oliguria. For which additional clinical manifestation associated with this cluster of info should the nurse assess the patient?

Weight gain

A nurse is inserting an indwelling urinary catheter for a male patient. What action will the nurse take? a. hold the shaft of the penis at a 60-degree angle b. hold the shaft of the penis with the dominant hand c. cleanse the meatus 3 times with the same cotton ball from clean to dirty d. cleanse the meatus with circular strokes beginning at the meatus and working outward

d. cleanse the meatus with circular strokes beginning at the meatus and working outward

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do? a. throw the catheter away and begin again b. fill the balloon with the recommended sterile water c. remove the catheter, wipe with alcohol, and reinsert after lubrication d. leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter

d. leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter

a client has a urinary tract infection. the client is told to take phenazopyridine (Pyridium) to decrease urinary discomfort. the client should be instructed that her urine will turn what color?

orange rationale: phenazopyridine (Pyridium) causes urine to turn bright orange

the nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. the presence of which of the following will support the potential diagnosis?

pus rationale: pyuria is the presence of pus in the urine. pyuria occurs in the presence of any UTI

To reduce patient discomfort during closed catheter irrigation, the nurse should

Use room temperature irrigation solution.

A patient is experiencing oliguria. Which action should the nurse perform first?

Assess for bladder distention.

1. Nurses should obtain information about urinary control from all female patients. T or F

True

Which clinical manifestation can a nurse expect when a postoperative patient experiences stress associated with surgery?

Decreased Urinary Output

Which s an effective nursing intervention to prevent UTI?

Encourage patients to drink several quarts of fluid daily.

A patient s reporting burning on urination. Which questions should the nurse ask to best obtain info about the patient's dysuria?

"Can you tell me about the problems you have been having with urination?"

Which assessment question should the nurse ask if stress incontinence is suspected?

"Do you experience urine leakage when you cough or sneeze?"

A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?

"Drink your nightly glass of milk earlier in the evening."

Which statement might the nurse make to nursing assistive personnel (NAP) assigned to care for a patient with an established suprapubic catheter? "Tell me if the catheter site looks inflamed." "I need to know the patient's temperature each time it's taken." "Wear sterile treatment gloves when you remove the dressing." "Let me know if the patient's catheter is infected"

"I need to know the patient's temperature each time it's taken." CORRECT. Temperature measurement can be delegated to NAP. This statement is appropriate for the nurse to make.

Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching?

"I will be anesthetized so that I lie perfectly still during the procedure."

The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? "I'll help you set up the sterile field." "I'll get a sterile urine cup for you." "There are leg straps in the utility room." "I'll help keep his legs away from the sterile field."

"I'll help keep his legs away from the sterile field." CORRECT. NAP can assist with intermittent straight catheterization by helping with patient positioning and comfort

Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" "See if the catheter is causing the patient any problems and if he is having any pain." "Please get two sterile urine collection containers from the utility room." "Let me know if the urine contains blood or sediment, or appears cloudy."

"Let me know if the urine contains blood or sediment, or appears cloudy." CORRECT. This statement correctly focuses on the characteristics of urine that an NAP must report to the nurse.

3. Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? "Tell me how he tolerates the irrigation." "Be sure to check for signs of a urinary tract infection." "Measure and report the patient's temperature to me every 4 hours." "Ask the patient about pain level."

"Measure and report the patient's temperature to me every 4 hours." CORRECT. This is the correct answer. Measuring and reporting temperature is a skill that may be delegated to NAP

A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding?

"My medication may discolor my urine; this should resolve once the medication is stopped."

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? "Please direct the light to better illuminate the patient's perineal area." "You need to be comfortable inserting a catheter in a patient of her size." "See if a size 14-French catheter is big enough." "Find out if the patient has any allergies to latex or iodine."

"Please direct the light to better illuminate the patient's perineal area." CORRECT. This is the correct answer. No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the nurse may delegate related tasks, such as redirecting the lighting during the procedure.

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? "Teach the patient the signs of a urinary tract infection." "Tell me when and how much the patient first voids." "Explain that voiding might be uncomfortable for 4 to 5 days." "Assess the patient for a distended bladder before the end of the shift."

"Tell me when and how much the patient first voids." CORRECT. The nurse may delegate to NAP the task of reporting the time and amount of the patient's first voiding after removal of an indwelling urinary catheter.

A nurse is caring for a patient who is taking phenazopyridine (Pyridium, a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish-red today; is there something wrong with me?" What would be the nurse's best response?

"This is a normal finding when taking phenazopyridine." Rationale: Pyridium is noted for turning the urine orange-red; the patient needs to be aware of this.

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking

"When was the last time you voided?"

What is the minimum length of an intermittent catheter that should be inserted through the urethral meatus in a male patient? Record your answer using a whole number. ________ cm

17 cm (7 inches) p. 1136

A nurse is assessing the urinary status of a patient. Which sign indicates that additional nursing assessments are necessary?

Specific gravity of 1.035

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply.

1. A 78-year-old male patient diagnosed with an enlarged prostate 2. A 75-year-old female patient who is diagnosed with vaginal prolapse 3. A 73-year-old female patient who is taking antihistamines to treat allergies Rationale: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.

1. What is the most significant change in kidney function that occurs with aging? 1) Decreased glomerular filtration rate 2) Proliferation of micro blood vessels to renal cortex 3) Formation of urate crystals 4) Increased renal mass

12. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse can conclude that learning occurs if the patient says, For 3 days prior to testing, I should avoid eating 1) Beef. 2) Milk. 3) Eggs. 4) Oatmeal.

13. The student nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because: 1) They are the leading cause of nosocomial infection. 2) They are too expensive for routine use. 3) They contain latex, increasing the risk for allergies. 4) Insertion is painful for most patients.

14. Which action should the nurse take to assess a 2-year-old child for pinworms? 1) Press clear cellophane tape against the anal opening to obtain a specimen. 2) Collect a freshly passed stool from a diaper using a wooden spatula. 3) Place a smear of stool on a slide and add two drops of reagent. 4) Prepare the patient for a flat plate (x-ray) of the abdomen.

16. A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother? 1) Consume a diet consisting of bananas, white rice, applesauce, and toast. 2) Drink large quantities of water regularly to prevent dehydration. 3) Take loperamide [an antidiarrheal] as needed to control diarrhea. 4) Increase the consumption of raw fruits and vegetables.

16. The surgeon orders hourly urine output measurement for a patient after abdominal surgery. The patients urine output has been greater than 60 ml/hour for the past 2 hours. Suddenly the patients urine output drops to almost nothing. What should the nurse do first? 1) Irrigate the catheter with 30 ml of sterile solution. 2) Replace the patients indwelling urinary catheter. 3) Infuse 500 ml of normal saline solution IV over 1 hour. 4) Notify the surgeon immediately.

18. A mother tells the nurse at an annual well child checkup that her 6-year-old son occasionally wets himself. Which response by the nurse is appropriate? 1) Explain that occasional wetting is normal in children of this age 2) Tell the mother to restrict her childs activities to avoid wetting 3) Suggest time-out to reinforce the importance of staying dry 4) Inform the mother that medication is commonly used to control wetting

18. The nurse assesses a patients abdomen 4 days after abdominal surgery and notes that bowel sounds are absent. This finding most likely suggest which postoperative complication? 1) Paralytic ileus 2) Small bowel obstruction 3) Diarrhea 4) Constipation

20. A patient with severe hemorrhoids is incontinent of liquid stool. Which of the following interventions is contraindicated? 1) Apply an indwelling fecal drainage device. 2) Apply an external fecal collection device. 3) Place an incontinence garment on the patient. 4) Place a waterproof pad under the patients buttocks.

20. Which action should the nurse take when beginning bladder training using scheduled voiding? 1) Offer the patient a bedpan every 2 hours while she is awake. 2) Increase the voiding interval by 30 to 60 minutes each week. 3) Frequently ask the patient if she has the urge to void. 4) Increase the frequency between voiding even if urine leakage occurs.

5. A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing? 1) Yogurt 2) Pasta 3) Oatmeal 4) Broccoli

5. The nurse identifies the nursing diagnosis Urinary Incontinence (Total) in an older adult patient admitted after a stroke. Urinary Incontinence places the patient at risk for which complication? 1) Skin breakdown 2) Urinary tract infection 3) Bowel incontinence 4) Renal calculi

7. The nurse measures the urine output of a patient who requires a bedpan to void. Which action should the nurse take first? Put on gloves and: 1) Have the patient void directly into the bedpan. 2) Pour the urine into a graduated container. 3) Read the volume with the bedpan on a flat surface at eye level. 4) Observe color and clarity of the urine in the bedpan.

1. Which factor(s) place(s) the patient at risk for constipation? Choose all that apply. 1) Sedentary lifestyle 2) High-dose calcium therapy 3) Lactose intolerance 4) Consuming spicy foods

1, 2

A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which teaching points would the nurse include? Select all that apply.

1. Drink eight to ten 8-oz glasses of water per day. 2. Limit caffeine-containing beverages. 3. Drink 10 oz of cranberry or blueberry juice daily. Rationale: It is recommended that a healthy adult drink eight to ten 8-oz glasses of fluid daily, limit caffeine because it is irritating to the bladder mucosa, and drink 10 oz of cranberry or blueberry juice daily to help prevent bacteriuria. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse.

A nurse is caring for a 56-year-old male patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply

1. Measure the patient's fluid intake and output. 2. Empty the appliance frequently. 3. Monitor the return of intestinal function and peristalsis. Rationale: When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucous in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply.

1. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. 2. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. 3. The nurse discards the first urine of the day when perform- ing a 24-hour urine specimen collection on a patient. Rationale: A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.

which of the following situations warrant urinary catheterization? select all that apply.

1. a client is in septic shock and highly unstable 2. a sterile urine sample is needed from an acutely confused client 3. a patient with an enlarged prostate is unable to void rationale: reasons for urinary catheterization include monitoring acutely ill clients, obtaining sterile urine specimens from clients who cannot otherwise provide them, and relieving urinary retention. the presence of a urinary tract infection doesn't indicate a need for catheterization. a client who is immobile should be introduced to the use of a bedpan or commode

the nurse is preparing to insert an indwelling catheter into a female client's bladder. arrange the following steps in the correct order.

1. open sterile catheterization tray using sterile techniques 2. don sterile gloves 3. open all sterile supplies 4. clean each labial fold, then the area directly over the meatus 5. slowly insert the lubricated catheter into the urethra 6. advance the catheter until there is a return of urine rationale: the catheter is not in the bladder, so urine in the tubing is not sterile

the nurse is preparing to assess a client's postvoid residual using a bladder scanner. arrange the following steps in correct order.

1. press appropriate gender button 2. position scanner head with directional arrow pointing to the head 3. press scanner head onto the skin 1 to 1.5 inches above the symphysis pubis 4. aim scanner head toward coccyx and activate scan 5. verify that the screen crossbars fall within bladder image 6. observe and record the volume measurement on the screen rationale: follow these steps when preparing to assess a client's postpaid residual using a bladder scanner

A primary health care provider orders a bladder ultrasound scan be performed after a patient voids to determine the amount of residual urine. The nurse explains the test to the patient. Place the following steps in the order that they should be performed by the nurse.

1.) Place the patient in the supine position 2.) Drape the patient exposing only the lower abdomen and suprapubic area 3.) Put 5 mL of conducting gel on the patient's symphysis pubis and press the scan head on the gel 4.) Aim the scan head toward the patient's cpccyx and press the scan head button 5.) obtain the bladder volume and repeat the measurement several times 6.) Clean the patient's abdomen to remove the gel and clean the scan head with isopropyl alcohol

After a transurethral prostatectomy, a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. In mL, how much of the total is urine output? Record your answer using a whole number and please note that no comma is needed. _______ mL

1320 mL he output is determined by calculating the amount of irrigation solution and subtracting that from the total output: 150 × 8 = 1200. Total output is 2520. 2520 - 1200 = 1320 urine output. p. 1144

1. When changing a diaper, the nurse observes that a 2-day-old infant has had a green black, tarry stool. What should the nurse do? 1) Notify the physician. 2) Do nothing; this is normal. 3) Give the baby sterile water until the mothers milk comes in. 4) Apply a skin barrier cream to the buttocks to prevent irritation.

11. The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis? 1) Prepare the patient for an abdominal flat plate. 2) Collect a stool specimen that contains 20 to 30 ml of liquid stool. 3) Administer a laxative to prepare the patient for a colonoscopy. 4) Test the patients stool using a fecal occult test.

11. Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer? 1) Patient will resume his normal urination pattern by (target date). 2) Patient will perform urostomy self-care by (target date). 3) Patient will perform self-catheterization by (target date). 4) Patients urine will remain clear with sufficient volume.

14. A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure? 1) I will need to replace the catheter weekly. 2) I can use clean, rather than sterile, technique at home. 3) I will remember to inflate the catheter balloon after insertion. 4) I will dispose of the catheter after use and get a new one each time.

15. The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure? 1) Semi-Fowlers position 2) Left sidelying position 3) Supine with the head of the bed lowered flat 4) Supine with the head of bed raised to 30 degrees

2. Based on the stage of physical development at which toilet training becomes physically possible, for which age would a goal of Achieves toilet training by the end of this month be most appropriate? 1) 18 months 2) 2 1/2 years 3) 3 1/2 years 4) 4 years

2. While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patients bladder. Which statement by the instructor is best? You should: 1) Try to palpate it again; it takes practice but you will locate it. 2) Palpate the patients bladder only when it is distended by urine. 3) Document this abnormal finding on the patients chart. 4) Immediately notify the nurse assigned to your patient.

21. A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug? 1) Hypocalcemia 2) Hypokalemia 3) Hypomagnesemia 4) Hypophosphatemia

22. Which daily urine output is within normal limits for a newborn weighing 8 pounds? 1) 288 ml 2) 180 ml 3) 36 ml 4) 18 ml

4. Which medication will the physician will most likely prescribe to increase urine output in the patient admitted with congestive heart failure? 1) Digoxin 2) Furosemide 3) Lovastatin 4) Atorvastatin

8. The nurse instructs a woman about providing a clean catch urine specimen. Which of the following statements indicates that the patient correctly understands the procedure? 1) I will be sure to urinate into the hat you placed on the toilet seat. 2) I will cleanse my genital area from front to back before I collect the specimen midstream. 3) I will need to lie still while you put in a urinary catheter to obtain the specimen. 4) I will collect my urine each time I urinate for the next 24 hours.

9. The nurse in a long-term care facility is teaching a group of residents about increasing fiber in their diet. Which foods should she explain are high in fiber? 1) White bread, pasta, and white rice 2) Oranges, raisins, and strawberries 3) Whole milk, eggs, and bacon 4) Peaches, orange juice, and bananas

1. Which of the following is/are an appropriate goal(s) for a patient with urinary incontinence? Choose all that apply. 1) Increase the intake of citrus fruits. 2) Increase daily oral fluids to 8 to 10 glasses per day. 3) Limit daily caffeine intake to less than 100 mg. 4) Engage in high-impact, aerobic exercise.

2, 3

3. The nurse must administer an enema to an adult patient with constipation. Which of the following would be a safe and effective distance for the nurse to insert the tubing into the patients rectum? Choose all that apply. 1) 2 inches 2) 3 inches 3) 4 inches 4) 5 inches

2, 3

A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because

Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void.

13. The nurse is instructing a patient about performing home testing for fecal occult blood. The nurse should explain that ingestion of which substance may cause a false-negative fecal occult blood test? 1) Vitamin D 2) Iron 3) Vitamin C 4) Thiamine

15. The nurse notes that a patients indwelling urinary catheter tubing contains sediment and crusting at the meatus. Which action should the nurse take? 1) Notify the provider immediately. 2) Flush the catheter tubing with saline solution. 3) Replace the indwelling urinary catheter. 4) Encourage fluids that increase urine acidity.

17. Which is a key treatment intervention for the patient admitted with diverticulitis? 1) Antacid 2) Antidiarrheal agent 3) Antibiotic therapy 4) NSAIDs

19. Which task can the nurse safely delegate to the nursing assistive personnel? 1) Palpating the bladder of a patient who is unable to void 2) Administering a continuous bladder irrigation 3) Providing indwelling urinary catheter care 4) Obtaining the patients history and physical assessment

21. A patient has a colostomy in the descending (sigmoid) colon and wishes to control bowel evacuation and possibly stop wearing an ostomy pouch. To help achieve this goal, nurse should teach the patient to: 1) Call the primary care provider if the stoma becomes pale, dusky, or black. 2) Limit the intake of gas-forming foods such as cabbage, onions, and fish. 3) Irrigate the stoma to produce a bowel movement on a schedule. 4) Avoid returning to the use of an ostomy appliance if he becomes ill.

23. The nurse is teaching an older female patient how to manage urge incontinence at home. What is the first-line approach to reducing involuntary leakage of urine? 1) Insertion of a pessary 2) Intermittent self-catheterization 3) Bladder training 4) Anticholinergic medication

24. What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter? 1) Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. 2) Briefly disconnect the catheter from the drainage tube to obtain sample. 3) Withdraw urine through the port using a needleless access device. 4) Obtain the urine specimen directly from the collection bag.

4. Which of the following goals is appropriate for a patient with a nursing diagnosis of Constipation? The patient increases the intake of: 1) Milk and cheese. 2) Bread and pasta. 3) Fruits and vegetables. 4) Lean meats.

6. A nurse is teaching wellness to a womens group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)? 1) 2 to 4 glasses a day 2) 4 to 6 glasses a day 3) 6 to 8 glasses a day 4) 8 to 10 glasses a day

6. The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take? 1) Do nothing; this is normal postoperative urine output. 2) Increase the infusion rate of the patients IV fluids. 3) Notify the provider about the patients oliguria. 4) Administer the patients routine diuretic dose early.

7. A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient? 1) Stop taking the drug immediately if diarrhea develops. 2) Take an antidiarrheal agent such as diphenoxylate. 3) Consume yogurt daily while taking the antibiotic. 4) Increase your intake of fiber until the diarrhea stops.

9. What position should the patient assume before the nurse inserts an indwelling urinary catheter? 1) Modified Trendelenburg 2) Prone 3) Dorsal recumbent 4) Semi-Fowlers

2. A patient who has been immobile since sustaining injuries in a motor vehicle accident complains of constipation. The nurse encourages him to consume 8 to 10 eight-ounce glasses of fluid daily. Which fluid(s) should the patient avoid because of the diuretic effect? Choose all that apply. 1) Cranberry juice 2) Water 3) Coffee 4) Ginger ale 5) Tea

3, 5

What is the minimum value of urinary output per hour that is considered normal before a nurse should immediately assess for the signs of blood loss? Record your answer using a whole number. _______ mL/hr

30 mL/hr If the urinary output falls below 30 mL/hr, the nurse should immediately assess for the signs of blood loss and notify the health care provider. A change in urine volume can be a significant indicator of fluid imbalance, kidney dysfunction, or decreased blood volume. p. 1111

10. A patient complains that she passes urine whenever she sneezes or coughs. How should the nurse document this complaint in the patients healthcare record? 1) Transient incontinence 2) Overflow incontinence 3) Urge incontinence 4) Stress incontinence

10. The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patients abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding? 1) Hyperactive bowel sounds 2) Abdominal bruit sounds 3) Normal bowel sounds 4) Hypoactive bowel sounds

12. Which intervention should the nurse take first to promote micturation in a patient who is having difficulty voiding? 1) Insert an indwelling urinary catheter. 2) Notify the provider immediately. 3) Insert a straight catheter. 4) Pour warm water over the patients perineum.

17. A patient is admitted with high BUN and creatinine levels, low blood pH, and elevated serum potassium level. Based on these laboratory findings the nurse suspects which diagnosis? 1) Cystitis 2) Renal calculi 3) Enuresis 4) Renal failure

19. A patient with a colostomy complains to the nurse, I am having really bad odors coming from my pouch. To help control odor, which foods should the nurse advise him to consume? 1) White rice and toast 2) Tomatoes and dried fruit 3) Asparagus and melons 4) Yogurt and parsley

3. The nurse has taught a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning? The patient: 1) Reduces her intake of gluten-containing products. 2) Does not consume foods that contain lactose. 3) Consumes only 4 cups of caffeinated coffee per day. 4) Takes measures to reduce her stress level.

3. Which urine specific gravity would be expected in a patient admitted with dehydration? 1) 1.002 2) 1.010 3) 1.025 4) 1.030

8. Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer? 1) Administering morphine 4 mg intravenously every 2 hours for pain 2) Administering IV fluids at 125 ml/hr 3) Inserting an indwelling urinary catheter to monitor I&O 4) Keeping the patient NPO until bowel sounds return

A primary health care provider orders 250 mL 0.9% sodium chloride to be administered over 30 minutes to challenge a patient's kidneys to produce urine. The nurse obtains an electronic infusion device to administer the solution. At what rate should the nurse program the infusion device?

500 mL/hour

What is the appropriate size of a urinary catheter used for infants? A. 5 to 6 Fr B. 6 to 7 Fr C. 8 to 9 Fr D. 9 to 10 Fr

A 5 to 6 Fr. p. 1120

A patient has bladder overactivity. What does the nurse expect to be the most likely cause? A. Spinal cord injury B. Anesthetic agents C. Prostatic enlargement D. Chronic pain syndromes

A A spinal cord injury or intervertebral disk disease can cause the loss of urine control because of bladder overactivity. Anesthetic agents given during surgery can decrease bladder contractility, which causes urinary retention. Prostatic enlargement can cause obstruction of the bladder outlet, which causes urinary retention. Chronic pain syndromes can interfere with the timely access to a toilet. p. 1102

For which test does the nurse ask the patient to come with a full bladder? A. Ultrasound of renal bladder B. Abdominal roentgenography C. Intravenous pyelography (IVP) D. Computerized axial tomography (CT) scan

A An ultrasound of the renal bladder is a test for imaging the kidneys, ureters, and bladder using sound waves to identify gross structural abnormalities and to estimate the volume of urine in the bladder. For this test, a nurse asks the patient to come with a full bladder. No special preparation is needed for abdominal roentgenogram. IVP and CT scan require a patient to restrict food and fluid intake for around 4 hours before the test. The nurse does not advise such patients to come with a full bladder. p. 1114

A patient complains of urinary alterations along with pain and discomfort at the time of voiding. What is the exact terminology that the nurse should know for this condition? A. Dysuria B. Oliguria C. Urgency D. Polyuria

A Dysuria is a condition where patients have pain and discomfort associated with voiding. Oliguria refers to reduced urinary output with regard to fluid intake. Urgency refers to an instant and strong desire to void that is not easily delayed. In polyuria, there is a voiding of excessive amounts of urine. p. 1110

A patient has a distended bladder on palpation, a high post void residual urine volume, a high frequency of micturition, and nocturia. Which type of urinary incontinence does the nurse suspect? A. Incontinence associated with chronic retention B. Incontinence because of causes outside the urinary tract C. Incontinence caused by treatable and reversible conditions D. Incontinence related to spinal cord damage between C1 to S2

A In urinary incontinence associated with chronic retention, the patient suffers from a distended bladder on palpation, high post void residual urine volume, high frequency of micturition, and nocturia. Incontinence because of causes outside the urinary tract may be due to inflammation, delirium, fecal impaction, and depression. Transient incontinence is caused by a medical condition; in many cases, this condition is treatable and reversible. Reflex urinary incontinence causes an involuntary loss of urine related to spinal cord damage between C1 to S2. p. 1104

A patient is diagnosed with stress urinary incontinence related to a weakened pelvic musculature. What teaching is the nurse least likely to provide to the patient? A. Use written and verbal instructions. B. Teach the patient pelvic muscle exercises. C. Instruct the patient to maintain adequate fluid intake. D. Teach the patient to avoid caffeine and other bladder irritants.

A The nurse normally uses written and verbal instructions in case the patient has deficient knowledge about urinary incontinence treatment. However the nurse may not issue these instructions when a patient has stress urinary incontinence related to a weakened pelvic musculature. The patient should be taught pelvic muscle exercises in case of weakened pelvic musculature. The nurse should instruct the patient to take in an adequate amount of fluid and water in case of stress urinary incontinence. Also, the patient should be taught to avoid caffeine and other bladder irritants. p. 1117

The nurse is caring for a patient who has an indwelling urinary catheter. Which action by the nurse increases the risk for patient complications? A. Allowing the drainage bag to get full before emptying B. Keeping the urinary drainage system closed C. Preventing urine backflow from the tubing and bag into the bladder D. Performing perineal hygiene after each bowel movement

A The nurse should not allow the drainage bag to get full before emptying. An overfull drainage bag creates tension and undue pressure on the catheter, which may induce trauma to the urethra or urinary meatus. The nurse should maintain a closed urinary drainage system that does not permit any channels for entry of pathogens. The nurse should make sure that there is no urine backflow from the tubing and bag into the bladder. The nurse should perform perineal hygiene after each bowel movement. p. 1122

What suggestion does the nurse give to a patient who asks for advice on how to prevent urinary tract infections? A. "Drink enough water to pass pale yellow urine." B. "Avoid straining when voiding or moving the bowels." C. "Take enough time to empty the bladder completely." D. "Avoid or limit drinking beverages that contain caffeine."

A The nurse should suggest that the patient drink enough water to pass pale yellow urine in order to prevent urinary tract infections. Avoidance of straining when voiding or moving the bowels and taking enough time to empty the bladder completely, indicate good voiding habits. Avoiding or limiting the consumption of beverages that contain caffeine sustains adequate hydration. p. 1118

The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient?

A 12-year-old female with severe abdominal trauma

The nurse would question an order to insert a urinary catheter on which patient?

A 30-year-old patient requiring drug screening for employment

The nurse would anticipate inserting a Coudé catheter for which patient?

A 56-year-old male admitted for bladder irrigation

A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination related to maturational enu- resis. Based on this diagnosis, for which patient is the nurse caring?

A child older than 4 years of age who has involuntary urination Rationale: Maturational enuresis is involuntary urination after an age when continence should be present. A 12-month-old child is not expected to be continent, and incontinence and neurologic damage are not maturational problems.

a (The nurse should document the client's condition as functional incontinence when the client is unable to retain urine for some time after getting an urge to void. Stress incontinence can result in the loss of small amounts of urine when intraabdominal pressure rises. Urge incontinence is the need to void perceived frequently with a short-lived ability to sustain control of flow. Total incontinence is the loss of urine without any identifiable pattern.)

A client at a health care facility complains to the nurse that when traveling, he is unable to retain urine until he locates a toilet. How should the nurse document this incontinence in the client? a) Functional b) Total c) Stress d) Urge

d (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 at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record? a) Inadequate elimination of urine b) Absence of urine c) Difficult or uncomfortable voiding d) Greater than normal urinary volume

a (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.)

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. Which of the following describes a urinary diversion? a) One or both of the ureters are surgically implanted elsewhere 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) Inability to control either urinary or bowel elimination

d (Stress incontinence can be described as loss of a small amount of urine when intra-abdominal pressure rises; whereas, urge incontinence can be described as the need to void is 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 at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? a) Need to void is perceived frequently, with short-lived ability to sustain control of flow b) Loss of urine control because a toilet in not accessible c) Loss of small amount of urine when intra-abdominal pressure rises d) Loss of urine without any identifiable pattern or warning

c (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 has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a a) Cystocele b) Overactive bladder c) Neurogenic bladder d) Enuresis

a (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 has been NPO after midnight for surgery. It is 11 AM 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? a) Dark amber b) Pale yellow c) Tea colored d) Colorless

a (Damage to the bladder neck may cause stress incontinence. The sudden, involuntary loss of small amounts of urine that accompanies a sudden increase in intra-abdominal pressure is called stress incontinence. Urinary tract infection, use of diuretics, and consumption of caffeine are associated with urge incontinence. The involuntary loss of urine after a strong feeling of the need to void is urge incontinence.)

A client is admitted to the healthcare facility with a diagnosis of stress incontinence. When reviewing the client's health record, which of the following would the nurse identify as a factor contributing to the client's condition? a) Damage to the bladder neck b) Consumption of caffeine c) Infection of the urinary tract d) Use of diuretics

b (The nurse should inform the client that amitriptyline turns the urine blue-green. The risk of urinary retention is increased with medications that have anticholinergic effects. Tricyclic antidepressants and antihistamines are examples of such drugs. Narcotics can decrease the sensation of bladder fullness and the glomerular filtration rate.)

A home care nurse visits a client diagnosed with depression who informs the nurse that he has been prescribed amitriptyline. Which of the following would the nurse include when teaching the client about the effects of this mediation? a) Decreases sensation of bladder fullness b) Causes urine to turn blue-green c) Decreases glomerular filtrate rate d) Causes urinary retention

While the nurse is performing closed catheter irrigation, the patient experiences pain. What is the nurse least likely to do? A. Assess for hypovolemic shock. B. Evaluate for a distended bladder. C. Examine the drainage tubing for clots, sediment, or kinks. D. Evaluate the urine for the presence of, or increase in, blood clots and sediment.

A nurse assesses the patient for hypovolemic shock in case there is bright-red bleeding with irrigation. This assessment is not necessary for a patient who experiences pain, but no bleeding. If the patient experiences pain while performing closed catheter irrigation, the nurse needs to evaluate for a distended bladder. Also, the nurse needs to examine the drainage tubing for clots, sediment, or kinks in case of pain. There is also a need to evaluate the urine for the presence of or increase in blood clots and sediment. p. 1145

d (f a thrill is not palpable and/or bruit is not audible, the nurse should notify the primary care provider immediately. The thrill and bruit are caused by arterial blood flowing into the vein. If these signs are not present, the access may be clotting off.)

A nurse assessing the access site of a hemodialysis catheter cannot palpate a thrill or hear a bruit. What is the most likely cause of this emergency situation? a) There is trauma to the bladder. b) There is leaking from the site. c) There is an infection at the site. d) The access may be clotting off.

b (During the training, the nurse plans a trial schedule for voiding that correlates with the time when the client is usually incontinent so as to reduce the potential for accidental voiding or sustained urinary retention. Compiling a log of the client's urinary elimination pattern helps reveal the client's type of incontinence. Setting realistic, specific, short-term goals for the client prevents self-defeating consequences. Discouraging strict limitation of fluid intake ensures adequate urine volume.)

A nurse at a health care facility provides continence training to a client. During the training, the nurse plans a trial schedule for voiding that correlates with the time when the client is usually incontinent. Which of the following is a possible reason for the nurse's action? a) Prevents self-defeating consequences b) Reduces potential for accidental voiding c) Reveals the client's type of incontinence d) Ensures adequate urine volume

a (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; and a balloon is inflated to ensure that the catheter remains in the bladder once it is inserted.)

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) Intermittent urethral catheter b) Indwelling urethral catheter c) Foley catheter d) Retention catheter

d (A fracture pan, a modified version of a conventional bedpan, is flat on the sitting end rather than rounded. Clients with musculoskeletal disorders who cannot elevate their hips and sit on a bedpan in the usual manner use a fracture pan. Clients who are weak or cannot walk to the bathroom may need a commode. Clients confined to bed use a urinal or bedpan.)

A nurse is caring for a 65-year-old male client with a musculoskeletal disorder at a health care facility. Which of the following should the nurse use in order to assist the client to eliminate urine? a) Urinal b) Commode c) Bedpan d) Fracture pan

c (The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to childbirth. The nurse should not document the condition as reflex incontinence, urge incontinence, or functional incontinence. Reflex incontinence is caused by damage to motor and sensory tracts in the lower spinal cord secondary to trauma. Urge incontinence is caused by bladder irritation secondary to infection. Functional incontinence is caused by impaired mobility, impaired cognition, or an inability to communicate.)

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? a) Urge incontinence b) Reflex incontinence c) Stress incontinence d) Functional incontinence

d (When providing continuous 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 and also cleans the urinary meatus when removing the catheter and not when irrigating the catheter.)

A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which of the following interventions should the nurse perform when providing continuous irrigation? a) Place the sterile solution on the bed b) Empty the balloon with a syringe c) Clean the urinary meatus d) Purge air from the tubing

b (Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept one to two inches -2.5 to 5 cm- beyond the tip of the penis to prevent irritation to the sensitive glans area.)

A nurse is caring for a client with an external condom catheter. Which of the following is a guideline for applying and caring for this type of catheter? a) Wash the penis with antimicrobial soap and dry thoroughly. b) Fasten the condom securely enough to prevent leakage without constricting the blood vessels. c) Keep the tip of the tubing two to three inches beyond the tip of the penis. d) Remove the catheter every eight hours, or more often in humid weather.

b (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 catheter is a urine drainage tube that is left in place over a period of time.)

A nurse is caring for an elderly client at his home. The client has had a condom catheter applied. Which of the following describes a condom catheter? a) A urine drainage tube inserted but not left in place b) A flexible sheath that is rolled around the penis c) A bag attached by adhesive backing to the skin around the genitals d) A urine drainage tube that is left in place over a period of time

a (Urine voided by a dehydrated client has a strong odor. A normal urine specimen has a faintly aromatic odor. A client with a urinary tract infection would have foul-smelling urine. Certain foods could contribute to the pungent odor of urine in a normal client.)

A nurse is examining the urine specimen of a dehydrated client. Which of the following is a characteristic odor of the urine voided by a dehydrated client? a) Strong b) Aromatic c) Foul d) Pungent

c (Patients should cleanse the catheter site after showering and should avoid baths and public pools. Once the site is healed, some physicians do not require patients to wear a dressing unless the site is leaking. Clean technique is sometimes allowed in the home.)

A nurse is preparing a discharge teaching plan for a patient being sent home with a peritoneal dialysis catheter in place. Which of the following is a recommended guideline that should be included in the instructions? a) A dressing should always be worn over the site to avoid leaking. b) Sterile technique must be observed by the patient in the home setting. c) The catheter exit site should be cleansed after showering. d) The patient may take a home bath, but should avoid public pools.

a (Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Results are most accurate when the client is in the supine position during the scanning.)

A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which of the following positions would the nurse place the client? a) Supine b) High Fowler's c) Sims' d) Dorsal recumbent

d (Kidney dysfunction could be a possible cause for the low volume of urination by the client. Diuretic medication and endocrine disease would increase the volume of urination. Liver disease would cause the urine to appear brown in color.)

A nurse notes that the volume of the client's urinary elimination is less than 300 mL/day. Which of the following could be the possible cause for the low volume of urination by the client? a) Diuretic medication b) Endocrine disease c) Liver disease d) Kidney dysfunction

b (Before performing the catheter irrigation, the nurse checks the client's record to verify that a medical order has been written as this demonstrates the legal limit of nursing. The nurse needs to verify the irrigation solution prescribed in order to comply with the medical directives. In order to provide a baseline for assessing the outcome, the nurse should assess the characteristics of the urine. The nurse determines how much the client understands about catheter teaching as it provides an opportunity for health teaching.)

A nurse performs catheter irrigation for a client at a health care facility only after verifying that a medical order has been written. Why should the nurse take this precaution? a) Provides an opportunity for health teaching b) Demonstrates legal limits of nursing c) Provides baseline for assessing outcome of procedure d) Complies with medical directives

a (The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home, because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter, also called an indwelling catheter, is left in place for a period of time.)

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? a) Straight catheter b) Retention catheter c) Condom catheter d) Urinary bag

A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate? a) Transient incontinence and increased urine production b) Increased output of dilute urine c) A risk of urinary tract infections d) Increased urine concentration

a (The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman's capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman's capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.)

A patient is suspected of having a disease process affecting the functional unit of the kidney. The nurse correctly recognizes which of the following stuctures is most likely involved? a) Nephron b) Glomerulus c) Bowman's capsule d) Loop of Henle

b (Suprapubic catheters are recommended for long-term continuous drainage because they are associated with a decreased risk of contamination with organisms from fecal material, the elimination of damage to the urethra, a higher rate of patient satisfactions, and a lower risk of UTIs.)

A physician orders a long-term continuous drainage system to monitor a critically ill patient. What type of catheter would best suit this patient's needs? a) External catheter b) Suprapubic catheter c) Indwelling urethral catheter d) Intermittent urethral catheter

a (A sterile urine specimen is not required for a routine urinalysis. Obtain and label the specimen and send it to the laboratory for examination. Do not leave the urine standing at room temperature for a long period of time before sending it to the laboratory because this may alter both the appearance and chemistry of the urine.)

A routine urinalysis has been ordered on a patient presenting to the emergency room with abdominal pain. What basic information does the nurse need to know to obtain this specimen? a) The nurse will obtain a nonsterile specimen and send it immediately to the lab. b) The nurse will obtain a sterile specimen and send it immediately to the lab. c) The nurse will obtain a nonsterile specimen, allow it to settle at room temperature for 2 hours, and then send it to the lab. d) The nurse will obtain a sterile specimen, allow it to settle at room temperature for 2 hours, and then send it to the lab.

a (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. 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.)

A sterile urine specimen for culture and sensitivity has been ordered 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 a syringe and needle. 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.

When caring for a patient with urinary retention, the nurse would anticipate an order for

A urinary catheter

c (Alcohol and caffeine-containing fluids or food, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.)

A woman complains of bladder urgency. It is most important to assess a) Vitamin supplements b) Exercise c) Caffeine intake d) Weight

d (A person's muscles may become so tense that relaxation of the perineal muscles does not occur, and voiding is inhibited.)

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) "You might have a neurologic condition." b) "What medications are you taking?" c) "You require greater privacy to void." d) "Stress causes the muscles to become tense."

The nurse, along with an nursing assistive person (NAP), is catheterizing a patient with a neurogenic bladder. What are the responsibilities of the NAP? Select all that apply. A. Maintain the privacy of the patient. B. Provide perineal care. C. Assist in the positioning of the patient. D. Insert catheter into the urethral meatus. E. Inflate the balloon fully as per the manufacturer's direction.

A, B, C Nursing assistive personnel (NAP) are responsible for maintaining the privacy of the patient. The NAP also provide perineal care before and after the procedure, and are responsible for assisting the nurse in positioning the patient for catheterization. Inserting the catheter into the urethral meatus and inflating the balloon of the catheter are skilled activities that should be performed by the nurse. p. 1140

A patient needs to undergo an intravenous pyelogram (IVP). What preparations should the nurse perform before starting the procedure? Select all that apply. A. Cleanse the patient's bowel. B. Assess for allergies. C. Encourage the patient to drink fluids to promote dye excretion. D. Restrict food and fluid intake up to 4 hours before the test. E. Assess for delayed hypersensitivity to the contrast media.

A, B, D During preparation of the patient who has to undergo an intravenous pyelogram (IVP), the nurse should cleanse the patient's bowel according to agency guidelines. The nurse should also assess for allergies and restrict food and fluid up to 4 hours before the test. The nurse should consider encouraging fluids to promote dye excretion after the IVP procedure. The nurse needs to assess for delayed hypersensitivity to the contrast media after the IVP procedure. p. 1114

What are the causes of transient incontinence? Select all that apply. A. Depression B. Fecal impaction C. Sensory impairment D. Cognitive impairments E. Excessive urine output

A, B, E Depression is a common reversible cause of transient incontinence. Fecal impaction and excessive urine output can also cause transient incontinence. Sensory impairment and cognitive impairment are possible causes of functional incontinence. p. 1104

What nursing skills should the nurse adopt to prevent a catheter-associated urinary tract infection (UTI)? Select all that apply. A. Secure the indwelling catheters. B. Empty the drainage bag when full. C. Maintain a closed urinary drainage system. D. Use dependent loops in the urinary drainage tubing. E. Keep the urinary drainage bag above the level of the bladder.

A, C The nurse should secure the indwelling catheters so that there is no movement and pulling of the catheter. The urinary drainage system should be closed to prevent any source of microbial infection. The nurse should empty the drainage bag when it is half full because an overfull drainage bag creates tension and undue pressure on the catheter, which may induce trauma to the urethra or urinary meatus. Dependent loops should be avoided in urine drainage tubing to reduce the possibility of applying back-pressure to the bladder. The urinary drainage bag should be kept below the level of the bladder at all times to ensure that there is no urine backflow from the tubing and bag into the bladder. p. 1122 Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation.

An older adult female reported urinary incontinence to the nurse. The patient is postmenopausal, overweight, and has a history of three vaginal births. She also has type 2 diabetes, which is being managed with medication and an appropriate diet. What should the nurse teach this patient? Select all that apply. A. "You should lose weight." B. "You should perform heavy exercise." C. "You should avoid heavy lifting." D. "You should perform pelvic muscle exercises." E. "You should drink less water."

A, C, D The nurse should teach the patient to lose weight, avoid heavy lifting, and perform pelvic muscle exercises. These measures reduce intraabdominal and bladder pressure that may increase leakage. The patient should avoid heavy exercise and drink an adequate amount of water. p. 1116

What are common causes of dysuria? Select all that apply. A. Trauma to the lower urinary tract B. Uncontrolled diabetes mellitus C. Inflammation of the prostate D. Urethritis E. Bladder outlet obstruction

A, C, D Trauma to the lower urinary tract, inflammation of the prostate, and urethritis are the common causes of dysuria. Uncontrolled diabetes mellitus is a common cause of polyuria. Bladder outlet obstruction can lead to dribbling. p.

The parents of a 7-year-old child complain that their child frequently awakens from sleep because of the urge to void. What may be the likely causes? Select all that apply. A. Diuretics B. Urethritis C. Diabetes insipidus D. Overactive bladder E. Urinary tract infection F. Trauma to the urinary tract

A, D, E Possible causes of nocturia include the use of diuretics, an overactive bladder, or a urinary tract infection. Urethritis causes dysuria. Diabetes insipidus causes polyuria. Trauma to the urinary tract causes hematuria. p. 1110

What are the major preventive actions that a nurse should know in order to inhibit catheter-associated infections? Select all that apply. A. Maintain a closed urinary drainage system. B. Evacuate the drainage bag when it gets full. C. Use dependent loops for urinary drainage tubing. D. Keep urinary drainage bags below the level of the bladder. E. Prevent urine backflow from the tubing and bag into the bladder.

A, D, E The risks of catheter-associated infections can be reduced by maintaining a closed urinary drainage system. The urinary drainage bag should be placed below the level of bladder at all times. The backflow of urine should be prevented from entering the bladder from the tubing and bag. The drainage bag should be emptied when it is half full. Dependent loops should be avoided in urinary drainage tubing. pp. 1121-1122

A patient complains of bladder discomfort as the nurse prepares to remove an indwelling catheter. What should the nurse assess? Select all that apply. A. Signs of infection B. Bladder distention C. Excessive urine volume in bladder D. Traction or pulling on the catheter E. Kinking or bending of the catheter, causing an occlusion of flow

A, D, E When a patient complains of bladder discomfort when removing an indwelling catheter, the nurse should assess for signs of infection and check the catheter to ensure that there is no traction or pulling. Also, the nurse should check the catheter for kinking or bending that may be causing occlusion to the flow. The nurse assesses for bladder distention or for excessive urine volume in the bladder if the patient is unable to void after catheter removal. p. 1139

A nurse is caring for a group of patients with a variety of urinary problems. Which patient's physical response should cause the most concern?

Anuria

The nurse is using different toileting schedules. Which principles will the nurse keep in mind when planning care? (Select all that apply) A. Habit training uses a bladder diary B. Timed voiding is based upon the patients urge to void C. Prompted voiding includes asking patients if they are wet or dry D. Elevation of feet in patients with edema can decrease nighttime voiding E. Bladder retraining teaches patients to follow the urge to void as quickly as possible

A. Habit training uses a bladder diary C. Prompted voiding includes asking patients if they are wet or dry

The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by

Administering an antihistamine medication to the patient.

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Which information is least important for the evaluation process?

Age of the patient Rationale: Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the plan of care.

c (Congenital malformations of the central nervous system may cause serious alterations in urinary elimination.)

An infant is born with spina bifida. She may have a) Excessive loss of sodium in the urine b) Increased urine production c) Alterations in urinary elimination d) Renal failure

c (The client is describing overflow 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.)

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 which of the following? a) Stress incontinence b) Urge incontinence c) Overflow incontinence d) Functional incontinence

Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter Performing proper hand hygiene and applying gloves before inserting the catheter Terminating the insertion if the patient reports pain at any time during the procedure

Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances CORRECT. This is the correct answer. Serious allergic reactions may occur if the patient has an allergy to latex, antiseptic, tape, or iodine-based cleanse

The nurse knows that indwelling catheters are placed before a cesarean because

Spinal anesthetics can temporarily disable urethral sphincters.

A nurse teaches a patient about altered urinary elimination. What factors should the nurse include in the teaching? A. "Alcohol decreases urine output." B. "Spinal cord injuries can cause the loss of urine control." C. "Phenazopyridine may cause the urine to appear intensely yellow." D. "Anesthetic agents given during surgery can increase bladder contractility."

B A spinal cord or intervertebral disk disease (above S-1) injury can lead to a loss of urine control. Following an injury, the bladder becomes overactive and there is impaired coordination between the contracting bladder and urinary sphincter. Alcohol decreases the release of antidiuretic hormones, which increases urine production. Phenazopyridine causes the urine to appear orange. Anesthetic agents given during surgery can decrease bladder contractility. p. 1102

What nursing intervention is the nurse least likely to provide to a patient diagnosed with stress urinary incontinence related to a weakened pelvic musculature? A. Encouraging the patient to lose weight B. Reinforcing teaching related to type 2 diabetes C. Advising the patient to maintain adequate hydration D. Instructing the patient to avoid caffeine and other bladder irritants

B If a patient is diagnosed with stress urinary incontinence related to a weakened pelvic musculature, the nurse is least likely to reinforce teaching related to type 2 diabetes. This type of teaching is needed in cases where there is risk of infection due to diabetes. A patient who has stress urinary incontinence related to a weakened pelvic musculature should be encouraged to lose weight and maintain adequate hydration. The nurse should also instruct the patient to avoid caffeine and other bladder irritants. p. 1117

What should the nurse do during the planning phase of the nursing process when caring for a patient who has altered urinary elimination? A. Inspect the character of the patient's urine. B. Reinforce adherence to good hygiene practices. C. Gather relevant laboratory and diagnostic test data. D. Have the patient and family demonstrate self-care skills.

B Reinforcing adherence to good hygiene practices forms a part of the planning phase of nursing process for urinary elimination. Inspecting the character of the patient's urine is part of the evaluation phase. During the assessment phase of the nursing process for urinary elimination, relevant laboratory and diagnostic test data is gathered. The patient and family may be asked to demonstrate self-care skills during the evaluation phase of the nursing process for urinary elimination. p. 1115

What is the appropriate size of a urinary catheter used for infants? A. 5 to 7 Fr B. 8 to 10 Fr C. 10 to 12 Fr D. 14 to 16 Fr

B The appropriate size of a urinary catheter used for children ranges from 8 to 10 Fr. Note that a 14 to 16 Fr catheter is used for adults to decrease trauma and risks of infections. p. 1120

A nursing instructor asks the nursing students about the function of the kidneys. Which statement by a student indicates the need for further learning? A. "The kidneys play a major role in blood pressure control via the renin-angiotensin system." B. "The kidneys produce erythropoietin, which decelerates red blood cell production in and the maturation of bone marrow." C. "The kidneys remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance." D. "The kidneys affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form."

B The kidneys produce erythropoietin, which stimulates (not decelerates) the production of red blood cells and their maturation in the bone marrow. The kidneys affect blood pressure control via the renin-angiotensin system, remove waste products from blood, and affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form, thereby regulating fluid and electrolyte balance. p. 1102

Which action should the nurse avoid when applying a condom catheter to a patient? A. Preparing the tubing B. Shaving the pubic area of the patient C. Performing a teach back to the patient D. Clipping the hair at the base of the penile shaft

B The nurse should not shave the patient's pubic area when applying a condom catheter. The nurse should prepare the tubing, drainage bag, and condom catheter. A teach back should be performed by the nurse to assess the patient's understanding about the catheter. The nurse should clip the patient's pubic hair at the base of the penile shaft, if necessary. p. 1125

What statement if made by a nursing student regarding glomerular filtrate indicates a need for further education? A. "One percent of the glomerular filtrate is excreted as urine." B. "The glomerulus always filters large proteins and blood cells." C. "Each nephron contains a cluster of capillaries called the glomerulus." D. "The glomerulus filters water, glucose, amino acids, urea, and uric acid."

B The presence of large proteins (proteinuria) or blood cells (hematuria) in the urine indicates glomerular injury. The glomerulus does not usually filter large proteins and blood cells. Only 1 percent of the glomerular filtrate is excreted as urine. The glomerulus is a cluster of capillaries contained in each nephron. Water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes are filtered by the glomerulus. p. 1101, 1102

What size urinary catheter should the nurse use for a 7-year-old child? A. 5 to 6 Fr B. 8 to 10 Fr C. 12 Fr D. 14 to 16 Fr

B The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the catheter. The catheter size to be used for children is 8-10 Fr. p. 1120

What finding in the patient's urinary report suggests the need for intervention? A. pH value of 7.4 B. Specific gravity of 1.1 C. Absence of red blood cells D. Protein value of 2 mg/100 mL

B The specific gravity of normal urine ranges from 1.0053 to 1.030. Elevated specific gravity values indicate dehydration, reduced renal blood flow, and increase in antidiuretic hormone (ADH) secretion, and thus needs intervention. The normal pH value ranges from 4.6 to 8.0. The absence of red blood cells in the urine is normal. A protein value of 2 mg/100 mL is also considered normal; protein values should not exceed 8 mg/100 mL. p. 1113

A patient is diagnosed with transient incontinence. What does the nurse explain to the patient about the cause of this type of urinary incontinence? A. "Transient incontinence is the loss of continence because of causes outside the urinary tract." B. "Transient incontinence is caused by medical conditions that are mostly treatable and reversible." C. "Transient incontinence is caused by urethral hypermobility or an incompetent urinary sphincter." D. "Transient incontinence is caused by an overdistended bladder; it is often related to bladder outlet obstruction."

B Transient incontinence is defined as incontinence caused by medical conditions that are generally treatable and reversible. Functional incontinence is incontinence due to causes outside the urinary tract. Stress urinary incontinence is defined as involuntary leakage of small volumes of urine associated with increased intraabdominal pressure related to either urethral hypermobility or an incompetent urinary sphincter. Urinary incontinence associated with the chronic retention of urine is the involuntary loss of urine caused by an overdistended bladder, which is often related to bladder outlet obstruction or poor bladder emptying due to weak or absent bladder contractions. p. 1104

What is the correct amount space allowed between the tip of the penis and the end of the catheter while placing a condom catheter on a patient? A. 1.5 to 3 cm B. 2.5 to 5 cm C. 3.5 to 5 cm D. 4.5 to 6 cm

B While placing a condom catheter on the patient, the nurse should allow a space of 2.5 to 5 cm (1 to 2 inches) between the tip of the penis and the end of the catheter. p. 1125

What is the normal pH range of urine? A. 2.6 to 4 B. 3.6 to 5 C. 4.6 to 8 D. 4.6 to 9

C 4.6 to 8. p. 1113

Under what conditions would a nurse instruct a patient to perform pelvic muscle exercises as directed by the health care provider? Select all that apply. A. Cognitive impairment B. Urethral hypermobility C. Bladder outlet obstruction D. Increased abdominal pressure E. Incompetent urinary sphincter F. Incontinence due to medical conditions

B, D, E In cases of urethral hypermobility, increased abdominal pressure, and an incompetent urinary sphincter, the nurse should teach the patient to perform pelvic muscle exercises. In cases of cognitive impairment, individualized toileting programs such as a habit training program, a scheduled toileting program, and a prompted voiding program need to be designed. In cases of bladder outlet obstruction, the nursing interventions are based on the degree of obstruction and may include catheterization. In cases of incontinence due to medical conditions, the nurse should look for any reversible causes and notify the health care provider of any suspected reversible causes. p. 1104

A nurse is providing care for a group of patients. Which patient will the nurse see first? A. A patient who is crippling small amounts on the way to the bathroom and has a diagnosis of urinary incontinence B. A patient with reflex incontinence with elevated blood pressure and pulse rate C. A patient with an indwelling catheter that has stool on the catheter tubing D. A patient who has just voided and needs a postvoid residual test

B. A patient with reflex incontinence with elevated blood pressure and pulse rate

The nurse anticipates a suprapubic catheter for which patient? A. A patient with recent prostatectomy B. A patient with urethral stricture C. A patient with an appendectomy D. A patient with menopause

B. A patient with urethral stricture

A nurse administers an antimuscarinic to a patient. What findings indicate the patient is having therapeutic effects from this medication? (Select all that apply) A. Decrease in dysuria B. Decrease in urgency C. Decrease in frequency D. Decrease in prostate size E. Decrease in bladder infection

B. Decrease in urgency C. Decrease in frequency

Which findings should the nurse follow up on after removal of a catheter from a patient? (Select all that apply) A. Increasing fluid intake B. Dribbling of urine C. Voiding in small amounts D. Voiding within 6 hours of catheter removal E. Burning with the firs couple times voiding

B. Dribbling of urine C. Voiding in small amounts

When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection?

Bacteria

The instructor asks a nursing student to name a type of continent urinary diversion that uses an ileal pouch to replace the bladder. Which answer given by student indicates adequate learning? A. Nephrostomy B. Ureterostomy C. Orthotopic neobladder D. Continent urinary reservoir

C An orthotopic neobladder is a type of continent urinary diversion that uses an ileal pouch to replace the bladder. A nephrostomy uses small artificial tubes that are tunneled through the skin into the renal pelvis when the ureter is obstructed. A ureterostomy is a permanent incontinent urinary diversion. A continent urinary reservoir is a continent urinary diversion that is created from the distal part of the ileum and the proximal part of the colon; it is situated under the abdominal wall. p. 1106

A nurse reviews a patient's urinary examination report. The presence of which component in the urine leads the nurse to suspect glomerular injury? A. Glucose B. Creatinine C. Large proteins D. Major electrolyte

C Because large proteins do not normally get filtered through the glomerulus, the presence of these molecules indicates a possible glomerular injury. The glomerulus filters glucose, creatinine, and major electrolytes. Therefore, these are normally found in the urine. p. 1101

What is the cause of functional incontinence? A. Fecal impaction B. Acute confusion C. Sensory impairment D. Excessive urine output

C Sensory impairment may cause functional incontinence. Fecal impaction, acute confusion, and excessive urine output are reversible causes of transient incontinence. p. 1104

What should the nurse teach a patient who has altered urinary elimination about maintaining a healthy bladder? A. "Drink ample fluids before bed time." B. "Drink three to four glasses of water daily." C. "Avoid drinking tea, coffee, or chocolate drinks." D. "Limit fluid intake if there is urinary incontinence."

C The nurse should teach the patient to avoid beverages that contain tea, coffee, or chocolate. Drinking fluids before bed time should be avoided because of the risk of nocturia. A patient should be advised to drink six to eight glasses of water a day. Fluid intake should not be limited even if there is urinary incontinence. p. 1118

What strategy should the nurse use to teach a patient to perform pelvic muscle exercises such as Kegel exercises? A. Use open-ended questions to determine the level of learning. B. Ask the patient to describe how to correctly identify the pelvic floor muscles. C. Use pictures to explain the pelvic anatomy and the location of the pelvic muscles. D. Ask the patient to demonstrate and/or explain how to perform pelvic muscle exercises.

C The nurse should use pictures and plain language to teach the patient pelvic anatomy and the location of the pelvic muscles. A nurse uses open-ended questions to determine the level of learning during the evaluation of patient teaching. The nurse also asks the patient to describe the correct identification of pelvic floor muscles and demonstrate the pelvic muscle exercises by performing as part of the evaluation of patient teaching. p. 1118

Which statement is true regarding the use of a bladder scanner to measure residual bladder volume? A. The patient is placed in the dorsal recumbent position. B. The scan measurement should be performed within 20 minutes of voiding. C. Women who have had a hysterectomy should be designated as male. D. Ultrasound gel is applied to the midline abdomen about 2.5 to 4 cm below the symphysis pubis.

C Women who have had a hysterectomy should be designated as male when setting the gender designation according to the manufacturer's guidelines. The patient is placed in a supine position, not dorsal recumbent. The scan measurement is conducted within 10 minutes of voiding, not 20. Ultrasound gel is applied to the midline abdomen about 2.5 to 4 cm above, not below, the symphysis pubis. p. 1123

2. The nurse is collecting a stool specimen. Arrange the following steps in the order the nurse should perform them. Label the steps from 1 to 4, with 1 being the first step to perform. A. Have the patient defecate into a special container placed under the toilet seat. B. Put on gloves and place the specimen in a specimen container. C. Ask the patient to void to empty the bladder. D. Place a label on the specimen container.

C, A, B, D

Which observation by the nurse best indicates that a continuous bladder irrigation for a patient following genitourinary surgery is effective? A. Output that is smaller than the amount instilled B. Blood clots or sediment in the drainage bag C. Bright red urine turns pink in the tubing D. Bladder distention with tenderness

C. Bright red urine turns pink in the tubing

Which should the nurse teach the patient to avoid to prevent urinary diuresis? (Select All That Apply)

Caffeine Alcohol

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? Using a 5-mL syringe to deflate the balloon Using sterile scissors to cut the valve to deflate the balloon Tugging gently on the catheter to pull the balloon through the urethra Checking the documentation for the volume of fluid used to inflate the balloon

Checking the documentation for the volume of fluid used to inflate the balloon CORRECT. Checking the volume of fluid used to inflate the balloon in order to ensure the balloon is completely deflated before removal is the nursing action that will minimize a patient's risk for injury during removal of an indwelling urinary catheter.

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? Checking the patency of the indwelling catheter tubing Placing the urinary collection bag below the level of the bladder Clamping the catheter tubing for 15 minutes before collection Asking the patient to drink a glass of water 30 minutes before the collection

Clamping the catheter tubing for 15 minutes before collection CORRECT. Clamping the catheter tubing for 15 minutes before collection will ensure that sufficient urine is available for the specimen.

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? Frequently pull on the drainage system tubing. Use the largest-size catheter possible. Clean the urinary meatus daily. Apply antiseptics to the urinary meatus.

Clean the urinary meatus daily. Apply antiseptics to the urinary meatus. CORRECT. To reduce the risk of CAUTI, daily cleansing of the urinary meatus is necessary.

Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? Attaching the urinary drainage bag to the bed frame Inspecting the drainage tubing for kinks Disposing of contaminated items after the procedure Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter

Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter CORRECT. This is the correct answer. Swabbing the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter reduces the number of pathogens that migrate from the tubing directly into the bladder.

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time? Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. Withdraw the catheter to 1 inch, and ask the patient to cough. Encourage the patient to cough as the catheter is advanced. Apply pressure to the patient's lower abdomen over the bladder.

Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. CORRECT. This is the correct option, because the urethra may be longer than 3 to 4 inches.

A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first? Notify the health care provider Apply pressure over the site Cover the site with a sterile dressing Help the patient into a side-lying position

Cover the site with a sterile dressing CORRECT. When a newly inserted suprapubic catheter becomes dislodged, the nurse's first action is to cover the site with a sterile dressing.

A patient is experiencing bladder irritability. Which fluid should the nurse teach the patient to include in the diet?

Cranberry Juice

A nurse asks a nursing student to name the contents of the intermittent catheterization kit. What answer if given by the student indicates the need for further teaching? A. Drapes B. Lubricant C. Single-lumen catheter D. Double-lumen catheter

D A double-lumen catheter is not a part of an intermittent catheterization kit. An intermittent catheterization kit contains drapes, lubricants, and a single-lumen catheter. p. 1131

A nursing instructor asks a nursing student to elaborate on nursing interventions for a patient experiencing stress urinary incontinence related to a weakened pelvic musculature. Which statement if made by the student indicates a need for further learning? A. "I should instruct the patient to avoid tea and coffee." B. "I should teach the patient to take in adequate water and fluid." C. "I should advise the patient to perform pelvic muscle exercises." D. "I should encourage the patient to increase intraabdominal pressure."

D A patient experiencing stress urinary incontinence related to a weakened pelvic musculature should be instructed to decrease (not increase) intraabdominal pressure. The patient should avoid tea, coffee and other bladder irritants. The patient should also have an adequate intake of fluid to stay hydrated and perform pelvic muscle exercises. p. 1117

What nursing intervention should the nurse provide to a patient who has wet skin due to urinary incontinence and is at risk for impaired skin integrity? A. Encouraging the patient to lose weight B. Advising the patient to maintain adequate hydration C. Using pictures to teach the patient about pelvic anatomy D. Teaching the patient to apply a moisture barrier product as needed

D A patient who is at risk for impaired skin integrity due to having wet skin caused by incontinence or old age should be taught to apply moisture barrier products as needed. A patient who has stress urinary incontinence related to a weakened pelvic musculature should be encouraged to lose weight and maintain adequate hydration. The nurse should use pictures to teach a patient who has deficient knowledge pertaining to urinary incontinence about pelvic anatomy. p. 1117

A patient has a delay in the start of the urinary stream when voiding. What is the least likely cause for this? A. Anxiety B. Urethral stricture C. Prostate enlargement D. Urinary tract infection

D A urinary tract infection (UTI) causes dysuria, urgency, increased frequency, nocturia, and hematuria. A UTI does not cause hesitancy or a delay in the start of a urinary stream when voiding. Anxiety, urethral stricture, and prostate enlargement may be the likely causes of hesitancy. p. 1110

What is the use of double-lumen catheters? A. Straight catheterization B. Intermittent catheterization C. Continuous bladder irrigation D. Urinary drainage and inflation of a balloon

D Double-lumen catheters are designed specifically for indwelling catheters, in which one lumen provides urinary drainage and the other inflates a balloon that keeps the catheter in place. Single-lumen catheters are used for straight catheterization. Additionally, single-lumen catheters are also used for intermittent catheterization. Triple-lumen catheters are used for continuous bladder irrigation. p. 1119

A female patient requires an indwelling catheter. What body position should the patient be placed in? A. Supine position B. Fowler's position C. Semi-sitting position D. Dorsal recumbent position

D For placing an indwelling catheter in a female patient, the nurse should have the patient in dorsal recumbent position. A male patient who requires an indwelling catheter should be in supine or Fowler's position. Semi-sitting position is the preferred position for a patient to void for collecting urine specimens. p. 1140

A patient's urinary report suggests microscopic hematuria. What is the most likely cause for this? A. Tumors B. Infection C. Urinary tract calculi D. Trauma to urinary tract

D Microscopic hematuria (blood not visualized but measured on urinalysis) is caused by trauma to the urinary tract. Tumors of the kidney, bladder, or other parts of the urinary tract are characterized by the presence of blood in the urine, which is visible to the eyes. In cases of infection or urinary tract calculi, gross hematuria (blood easily seen in urine) is present. p. 1110

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output?

Decreased and highly concentrated Rationale: Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.

1. When performing an abdominal assessment, what sequence of assessment techniques should the nurse use? Label the steps from 1 to 4, with 1 being the first step to perform. A. Auscultation B. Palpation C. Percussion D. Inspection

D, A, C, B

3. When administering an enema, list the following steps in the order in which they should be performed. Label the steps from 1 to 6, with 1 being the first step to perform. A. Document the results of the procedure. B. Assess the patient for cramping. C. Insert the tubing about 3 to 4 inches into the rectum. D. Lubricate the tip of the enema tubing generously. E. Raise the container to the correct height and instill the solution at a slow rate. F. Encourage the patient to hold the solution for 3 to 15 minutes, depending on the type of enema.

D, C, E, B, F, A

When establishing a diagnosis of altered urinary elimination, the nurse should first

Discuss causes and solutions to problems related to micturition.

A nurse is performing a physical assessment ona newly admitted patient. Which problem identified by the nurse is often associated with urinary continence?

Disturbed self-esteem

A nurse must obtain a urine specimen for a culture and sensitivity test from a patient who has an indwelling urinary catheter. Place the following steps in order from which they should be performed.

Drain the urine in the tubing into the drainage bag Clamp the drainage tubing below the specimen port for 15 to 30 mins Wash your hands and don clean gloves Swab the specimen port with an antiseptic and aspirate urine via a sterile syringe Transfer the urine to a sterile specimen cup and discard the syringe into a sharps container Remove the clamp from the drainage tubing

c (Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet.)

During a visit to the pediatrician's office, a parent inquires about toilet training her daughter age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when ... a) the child can hold the urine for four to five hours. b) The child ignores the desire to void. c) the child can recognize bladder fullness. d) The child cannot control urination until seated on the toilet.

A patient with a suprapubic catheter is complaining of pain. What will the nurse do first to help this patient? Ensure that the patient is not lying on the drainage tubing Instruct the patient to increase his or her oral fluid intake Observe the rate of drainage in the urine collection bag Notify the health care provider

Ensure that the patient is not lying on the drainage tubing CORRECT. The nurse will first ensure that the patient is not lying on the drainage tubing, since doing so could obstruct urine flow and cause pain.

A nurse is caring for a female patient on bedrest who has a urinary retention catheter. Which should the nurse do? (Select All That Apply)

Ensure the tubing is positioned over the leg Secure the tubing to the patient's leg

A patient has a urinary retention catheter. Which is the most important when the nurse cares for this patient?

Ensuring that the catheter remains connected to the collection bag.

During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? Examine the drainage tubing for clots, sediment, and kinks. Notify the health care provider. Leave the irrigation drip wide open. Monitor the patient's vital signs.

Examine the drainage tubing for clots, sediment, and kinks. CORRECT. This is the correct answer. If the patient complained of pain during intermittent open bladder irrigation, the nurse would first examine the drainage tubing for clots, sediment, and kinks.

Which info about a patient is communicated when a nurse documents that the patient has polyuria?

Excreting excessive amounts of urine

Which is not an expected outcome on a first voiding after catheter removal? Mild burning Fever and back pain Producing only a small amount of urine Discomfort

Fever and back pain CORRECT. The nurse would instruct the patient to report signs of a urinary tract infection, such as fever and back pain. These signs are unlikely to be present during the patient's first voiding after catheter removal.

What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine?

Fever and chills

Which measure may be taken to minimize the staff's risk for infection from a urine specimen? Firmly securing the lid of the urine specimen container Using a sterile urine specimen container Using a sterile syringe to access the sampling port Placing the urine specimen container in the refrigerator until the laboratory comes to get it

Firmly securing the lid of the urine specimen container CORRECT. Securing the specimen container lid is one way to minimize the risk for infection to the staff.

The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom?

Frequency

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding?

Glomerular filtration rate of 20 mL/min

A nurse must measure the intake and output (I&O) of a patient who has a urinary retention catheter. Which equipment is MOST appropriate to use to measure urine output from a urinary retention catheter accurately?

Graduate

A nurse notifies the provider immediately if a patient with an indwelling catheter

Has not collected any urine in the drainage bag for 2 hours.

A primary health care provider discusses the need for a cystoscopy with a patient. Which is most important for the nurse to do when caring for this patient before the procedure?

Have the patient sign an informed consent form before the procedure.

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? Placing the specimen in a biohazard bag Having someone take the specimen to the lab immediately Cleaning the outside surface of the container Ensuring that a stock of sterile urine collection kits is available

Having someone take the specimen to the lab immediately CORRECT. Having someone take the specimen to the lab immediately will help to ensure reliable results. The specimen must be delivered to the lab within 20 minutes of collection.

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased dif- ficulty with voiding?

Having the patient ignore the urge to void until her bladder is full. Rationale: Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding.

To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to

Hold the labia apart while voiding into the specimen cup.

Which method should the nurse use to collect a urine specimen of a patient who has an indwelling catheter? A. Collect 3 to 5 mL of the specimen from the drainage bag. B. Collect 6 to 8 mL of the specimen from the drainage bag. C. Clean the port with an alcohol swab, insert a sterile hub, and withdraw at least 3 to 5 mL of urine. D. Insert a sterile hub and withdraw at least 6 to 8 mL of urine.

If the patient has an indwelling catheter, the nurse should clean the port with an alcohol swab, insert a sterile hub, and withdraw at least 3 to 5 mL of urine. The specimen should not be collected from the drainage bag. p. 1112 Test-Taking Tip: Do not select answers that contain exceptions to the general rule, controversial material, or degrading responses.

A patient returns from the surgical unit after a transurethral resection of the prostate gland. The nurse reviews the primary health care provider's orders, obtains the patient's vital signs, and performs a focused patient assessment. Which is the best intervention by the nurse?

Increase the flow rate of the continuous bladder irrigation

which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? Increase the irrigation drip rate. Notify the patient's health care provider of the blood and clots in the urine. Encourage the patient to increase fluid intake. Apply ice to the patient's lower abdominal area. CORRECT. This is the correct answer. The nurse wo

Increase the irrigation drip rate. CORRECT. This is the correct answer. The nurse would increase the irrigation drip rate to flush the urinary tract until the urine was only tinged pink with blood.

An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate?

Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

A nurse is inserting an indwelling urinary catheter into a male patient. The nurse feels firm resistence while inserting the urinary catheter through the penis. What should the nurse do?

Interrupt the procedure and notify the primary health care provider

The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis?

Intravenous pyelogram

A nurse anticipates urodynamic testing for a patient with which symptom?

Involuntary urine leakage

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)? Measure and empty the urine. Palpate the abdomen. Ask the patient if she has any pain. Document the procedure.

Measure and empty the urine. CORRECT. The NAP can measure and empty the urine collection tray after an intermittent straight catheterization.

While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? Remove the catheter, and rinse it thoroughly in sterile water for reuse. Keep the catheter in place, and begin again with a new sterile catheter. Remove the catheter, relubricate it, and insert it into the urinary meatus. Stop advancing the catheter, and notify the health care provider.

Keep the catheter in place, and begin again with a new sterile catheter. CORRECT. This action is correct. If a straight catheter is inadvertently inserted into the vagina, it should be left in place as a landmark, and the nurse must begin the catheterization process again with a new sterile catheter

Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.)

Labeling all specimens with date, time, and initials Allowing the patient adequate time and privacy to void Transporting specimens to the laboratory in a timely fashion Placing a plastic bag over the child's urethra to catch urine

Limit fluid and caffeine intake before bed.

A nurse is caring for two patients. One patient has reflex incontinence and the other has total incontinence. Which characteristic is common to both reflex incontinence and total incontinence?

Loss of urine without awareness of bladder fullness

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? Remove the cotton balls from the kit for later use. Advance the catheter 10 to 12 inches or until urine flows. Lubricate the first 5 to 7 inches of the catheter. Hold the penis at a 45-degree angle during insertion.

Lubricate the first 5 to 7 inches of the CORRECT. The first 5 to 7 inches of the catheter is lubricated to ease insertion.

Which of the following is the primary function of the kidney?

Maintaining fluid and electrolyte balance

An older adult with an indwelling urinary catheter is recieving 75 mL of 0.9% sodium chloride hourly. The patient has had several hospital admissions in the last year for dehydration. The nurse is concerned about the patient's renal function. What is the best intervention by the nurse to assess the patient's renal functioning?

Monitor for patient's urine output every shift.

A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient?

Monitor the patient for fever, rash, and difficulty breathing.

Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.)

Nausea and vomiting Headache Altered mental status

A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the irrigant will not enter the catheter. What intervention would the nurse appropriately perform next?

Notify the primary care provider. Rationale: If the irrigation solution will not enter the catheter, the nurse should not force the solution into the catheter; instead, the nurse should notify the primary care provider and prepare to change the catheter.

Which nursing actions should be implemented by a nurse to facilitate bladder continence for a male patient who is cognitively impaired? (Select All That Apply)

Offer toileting reminders every 2 hours Provide clothing that is easy to manipulate

Which clinical manifestation identified by the nurse commonly is associated with excessive production of antidiuretic hormone (ADH)?

Oliguria

b (The effectiveness of therapy is determined by the urine characteristics. On completion of the therapy with continuous bladder irrigation, the patient should exhibit urine that is clear, without evidence of clots or debris.)

On what factor is the effectiveness of continuous bladder irrigation based? a) The absence of infection b) The characteristics of the urine c) The flow rate of the urine d) The frequency of urination

Which of the following are indications for irrigating a urinary catheter? (Select all that apply.)

Sediment occluding within the tubing Blood clots in the bladder following surgery Bladder infection

A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to

Perform pelvic floor exercises.

When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection?

Performing hand hygiene before and after providing perineal care

4, 1, 6, 5, 3, 2

Place the following steps in the correct order. Question: The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. Arrange the following steps in the correct order. 1 Don sterile gloves. 2 Advance the catheter until there is a return of urine. 3 Slowly insert the lubricated catheter into the urethra. 4 Open sterile catheterization tray using sterile technique. 5 Clean each labial fold, then the area directly over the meatus. 6 Open all sterile supplies.

The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection?

Placing the drainage bag on the side rail of the patient's bed

A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the PRIORITY when planning to meet the patient's needs?

Positioning a bedside commode near the bed

A nurse is caring for a male patient who had a condom catheter applied following hip surgery. What action would be a priority when caring for this patient?

Preventing the tubing from kinking to maintain free urinary drainage Rationale: The catheter should be allowed to drain freely through tubing that is not kinked. It also should be removed daily to pre- vent skin excoriation and should not be fastened too tightly or restriction of blood vessels in the area is likely. Confining a patient to bedrest increases the risk for other hazards related to immobility.

A nurse identifies that the patient has overflow incontinence. Which factor contributes to this clinical manifestation?

Prostate enlargement

A nurse reviews the results of a patient's urinalysis. Which constituent found in urine indicates the presence of an abnormality?

Protein

A nurse must obtain a urine specimen from a patient. Which nursing intervention is the greatest help to most people who need to void for a urine test?

Providing for privacy

A patient has urinary incontinence. Which is the best nursing intervention for this patient?

Providing skin care immediately after soiling.

The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? Begin to establish a sterile field. Open and assemble the urine drainage bag. Remove soiled gloves, and perform hand hygiene. Center the drape over the patient's labia.

Remove soiled gloves, and perform hand hygiene. CORRECT. This is the correct answer. The nurse's soiled gloves must be removed prior to setting up the sterile field.

While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? Rinse off the supplies that were contaminated with urine. Cleanse the patient's urinary meatus. Replace all contaminated supplies, and begin the process again. Change the patient's bed linens.

Replace all contaminated supplies, and begin the process again. Change the patient's bed linens. CORRECT. If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, all contaminated supplies must be replaced and the process begun again.

A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? Reassure the patient that the procedure will take only a few minutes. Promise to reposition the patient as soon as the catheter has been inserted. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. Explain to the patient that the position will allow the catheter insertion to be more efficient.

Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. CORRECT. This is the correct answer. The side-lying (Sims') position is an acceptable alternative that may be more comfortable for the patient.

Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority?

Risk of infection

Which nursing action reduces the risk of injury in a patient with a suprapubic catheter? Applying sterile gloves before cleaning the catheter insertion site Cleansing the skin surrounding the insertion site Securing the catheter to the abdomen Keeping the drainage bag above the level of the patient's bladder

Securing the catheter to the abdomen CORRECT. Securing the catheter to the abdomen will reduce the risk of injury to the patient by ensuring that excess tension is not applied to the catheter. Such tension could damage the bladder

a, d, e (To maintain the integrity of the peristomal skin, the nurse uses skin barrier products, and antibiotic or steroid ointment is applied. It is often difficult to maintain the integrity of the peristomal skin because of the frequent appliance changes and the ammonia in urine. When changing the urinary appliance, the nurse could place a tampon within the stoma to absorb urine temporarily while the skin is cleansed and prepared for another appliance. A disposable pad is used when providing catheter care to protect the bed linen from becoming wet or soiled.)

Select all answer choices that apply. A nurse is caring for a client with urostomy following bladder blockage due to cancer. Which of the following should the nurse use to maintain the integrity of the peristomal skin? Select all that apply. a) Steroid ointment b) Tampons c) Disposable pad d) Antibiotic ointments e) Skin barrier products

b, c, e (If the sheath is applied too tightly, it restricts blood flow to the skin and tissues of the penis, moisture tends to accumulate beneath the sheath leading to skin breakdown, and the catheter may frequently leak. A retention catheter used to manage urinary incontinence could lead to urinary tract infection. Use of a condom catheter does not lead to the inability to control urinary elimination.)

Select all answer choices that apply. A nurse is caring for an elderly client who has been prescribed a condom catheter. Which of the following are the common problems that a client can experience when using a condom catheter? Select all that apply. a) May lead to urinary tract infection b) May accumulate moisture beneath the sheath c) May restrict the flow of blood to the skin and tissues d) May lead to an inability to control urinary elimination e) May lead to frequent leakage

c, e, f (The nurse should palpate for bladder distention; if patient is lying supine, roll the patient onto his or her side to help increase the amount of drainage. The nurse should also check to make sure that the tubing is not kinked and if return flow remains decreased, notify the physician.)

Select all answer choices that apply. A nurse performing continuous bladder irrigation on a patient notes that hourly drainage is less than amount of irrigation being given. Which of the following interventions would be appropriate in this situation? Select all that apply. a) Remove the catheter in place. b) Lower the bag 3 to 6 inches and recheck the patient. c) If return flow remains decreased, notify the physician. d) Roll the patient onto his or her back e) Check to make sure that the tubing is not kinked. f) Palpate for bladder distention.

a, b, d, e

Select all answer choices that apply. Which of the following statements accurately describe the effects of food and fluid intake on the amount and quality of urine produced by the body? Select all that apply. a) Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. b) Ingestion of foods and beverages high in sodium content leads to increased urine formation. c) Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine. d) Fluid overload leads to excretion of a large quantity of dilute urine. e) Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. f) Consumption of alcoholic beverages leads to increased urine production due to their stimulation of antidiuretic hormone release.

b (Limiting fluid intake is not a healthy practice, and patients should be encouraged not to use fluid restriction as an incontinence management strategy. Promoting fluid intake is beneficial for most patients who do not possess a contraindication, and it is appropriate and useful to take diuretics in the morning to avoid nocturia. Even though it may involve work for both the patient and the nurse, patients who want to use a bathroom or commode rather than an adult brief should be encouraged to do so.)

Several of the patients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which of the following statements suggests that the patient requires further teaching? a) "I know it's hard to get there, but I want to try to use the commode instead of wearing an adult diaper." b) "I make sure to limit how much I drink so that I don't have accidents." c) "I've made a point of scheduling when I drink water instead of waiting until I'm thirsty." d) "At home, I take my water pill in the morning so that I don't have to use the bathroom as much during the night."

Which assessment is not related to monitoring both urine and stool?

Shape

When planning nursing care, which factors in the patient's history place the patient at risk for stress incontinence? (Select All That Apply)

Six Vaginal Births Menopause

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? Sterile technique protects the patient from microorganisms in the urine. Sterile technique protects the nurse from microorganisms in the urine. Sterile technique reduces the amount of pain caused by the procedure. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. CORRECT. The nurse will use sterile technique to obtain a urine specimen from an indwelling urinary catheter to ensure that any microorganisms in the specimen are from the urine, not from the patient's skin, the nurse's hands, or the environment.

When a nurse assesses a patient, which clinical manifestations support the presence of urinary retention? (Select All That Apply)

Suprapubic distention Frequent small voidings

The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be

Sweet smelling.

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient?

Teach the patient to perform Kegel exercises at regular intervals daily Rationale: Kegel exercises may help a patient regain control of the micturition process. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. An indwelling catheter is the last choice of treatment.

Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? The collection bag has been placed on the side rail of the bed. The excess catheter tubing has been coiled beside the patient's inner thigh. The collection bag has been placed on the bed. The collection bag is held above the level of the bladder while ambulating the patient.

The excess catheter tubing has been coiled beside the patient's inner thigh. ambulating the patient. CORRECT. The excess drainage tubing should be coiled next to the patient's inner thigh, to facilitate urine flow.

The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure?

The male urethra is more vulnerable to injury during insertion Rationale: Because of its length, the male urethra is more prone to injury and requires that the catheter be inserted 6′′ to 8′′. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.

b (The nurse should adhere to the nursing process, with assessment preceding interventions such as reinserting the patient's catheter, even if a standing order exists to reinsert the catheter if needed. Similarly, a diuretic would not be the first course of action. A short-term lack of urine output, especially following the removal of a catheter, is not indicative of renal failure.)

The nurse has been closely monitoring a patient who has recently had her indwelling urinary catheter removed. In the six hours since the catheter was removed, the patient has yet to void. How should the nurse first respond to this assessment finding? a) Reinsert the patient's urinary catheter. b) Assess the patient's bladder by palpation and bedside ultrasound. c) Obtain an order for an oral diuretic and administer this drug to the patient. d) Inform the physician and request blood work to assess the patient's renal function.

c (Oliguria is a significant decrease in urine production. Anuria is an absence or near-absence of urine output, while nocturia is nighttime awakening to void and polyuria is greatly increased urine production.)

The nurse has entered a patient's room to empty the patient's urine collection bag at the end of a busy shift. The nurse realizes that the patient's urine output is 75 mL over the past 8 hours. The nurse would recognize that the patient is experiencing which of the following? a) Nocturia b) Polyuria c) Oliguria d) Anuria

c (Trauma from vaginal delivery causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period.)

The nurse is caring for a patient who has been experiencing difficulty voiding since her vaginal birth. The patient voices concern to the nurse. What information should be provided to the patient? a) A neurogenic bladder results from local anesthesia b) Catheterization is necessary for 1 week c) The delivery can cause perineal swelling d) A urinary tract infection results from the birth process

d (If the patient complains of pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the patient's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 1/2 to 1 -1.22.4 cm-, and slowly attempt to inflate the balloon again. Reattempting inflation in the same location or after withdrawing slightly could cause trauma to the patient's urethra. It is not necessary to utilize a smaller gauge catheter.)

The nurse is inserting a urinary catheter into a female patient and has begun to inflate the balloon, an action that has caused the patient to wince and cry out in pain. Consequently, the nurse should do which of the following? a) Deflate the balloon, withdraw the catheter, and use a smaller sized catheter. b) Stop, deflate the balloon, withdraw the catheter 2 to 4 cm, and slowly reinflate. c) Wait for 30 seconds, help the patient to relax, and reattempt inflation. d) Deflate the balloon, insert the catheter further, and slowly attempt reinflation.

c (Educational points related to an indwelling urinary catheter include instructions on connecting the catheter to a smaller leg bag for ambulation; maintaining adequate fluid intake; keeping the catheter free of kinks -avoid clamping the catheter tubing-; emptying the drainage bag at regular intervals; and avoiding a full drainage bag that may lead to reflux of urine.)

The nurse is providing teaching to a client who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the client? a) Restrict daily fluid intake. b) Clamp the catheter tubing daily for two hours and then release the clamp at night. c) The catheter can be connected to a smaller leg bag for ambulation. d) Empty the catheter bag every few days when it is full.

Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. A registered nurse, not NAP, must remove the catheter. Catheter removal must be executed within 10 minutes of beginning the procedure. Catheter removal must take place within 5 days of catheter insertion.

The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. CORRECT. Using clean technique is the best way to minimize the risk of introducing pathogens to the patient's urinary trac

c (The purpose of continuous bladder irrigation is to prevent catheter blockage, usually by a blood clot. Consequently, recent urological surgery may necessitate such a measure. Incontinence does not create a need for intermittent or continuous bladder irrigation and a woman who has given birth is similarly unlikely to require continuous irrigation of her bladder and urethra.)

The nurse should recognize the possibility of maintaining a continuous bladder irrigation system when admitting which of these patients? a) A patient who is functionally incontinent due to the progression of Alzheimer disease b) A patient with multiple sclerosis who has been experiencing urinary incontinence c) A patient who has undergone prostate resection surgery that morning d) A patient who has had a spontaneous vaginal delivery of her first baby earlier that day

b (The side-lying position is especially used for clients who have limited hip mobility because it permits excellent visualization of the urinary meatus. Usually, female clients are placed in a dorsal recumbent position for catheterization, and male clients are put in a supine or semi-Fowler's position.)

The physician orders an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bedrest. When inserting the catheter, the nurse would place the client in which position? a) Dorsal recumbent position b) Side-lying position c) Supine position d) Semi-Fowler's position

Within what duration of voiding should the scan measurement be performed for measuring residual bladder volume? Record your answer using a whole number. _______ minutes.

The scan measurement should be done within 10 minutes of voiding. p. 1123

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia?

The stoma is a purple-blue color. Rationale: A purple-blue stoma may reflect compromised circulation or ischemia. A pale stoma may indicate anemia. The stoma may be swollen at first, but that condition should subside with time. A normal stoma should be moist and dark pink to red in color.

What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? To increase oxygenation To reduce blood pressure To distract him To promote relaxation

To promote relaxation CORRECT. The nurse would instruct a male patient to take slow, deep breaths during catheter insertion if the nurse felt resistance to the advancing catheter or if the patient reported pain. Deep breathing promotes relaxation, which might help to pass the catheter through the urinary sphincter.

What is the primary reason the nurse applies sterile gloves rather than clean ones when caring for a patient with a newly inserted suprapubic catheter? To protect the nurse and other patients from pathogens To collect a sterile urine sample To reduce the patient's risk of infection To reduce the patient's risk of injury

To reduce the patient's risk of infection CORRECT. This is the correct answer. When providing care for a newly inserted suprapubic catheter, the nurse wears sterile gloves to reduce the risk of infecting the wound at the catheter insertion site.

Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? To encourage the bladder to drain fully To encourage spontaneous voiding To prevent bowel elimination during the procedure To reduce the patient's risk of urinary tract infection

To reduce the patient's risk of urinary tract infection CORRECT. The nurse cleanses a female patient's perineum before inserting an intermittent urinary catheter in order to reduce the patient's risk of infection

A patient tells the nurse, "I have to urinate as soon as i get the urge to go." For which contributing factor to urinary urgency should the nurse implement a focused assessment?

UTI

c (The antidepressant amitriptyline -Elavil- or B-complex vitamins can turn urine green or blue-green. Anticoagulants may cause blood in the urine -pink or red color. Phenazopyridine -Pyridium-, a urinary analgesic, can cause orange or orange-red urine. Levodopa -L-dopa-, an antiparkinson drug, and injectable iron compounds can lead to brown or black urine.)

Upon admission, the patient informs the nurse of the medications he takes daily at home. When the nurse learns that the patient takes amitriptyline (Elavil), she anticipates the patient's urine may have which discoloration? a) Pinkish-red b) Orange-red c) Blue-green d) Brownish-black

b (Conservation of fluid by the body during states of underhydration, fever, and diaphoresis results in the production of concentrated urine that is dark in color. A sign of overhydration would be very light or clear urine. Adequate fluid intake would correspond with pale yellow and clear urine. Signs of urinary tract infection include cloudy urine or urine containing blood or blood cells.)

Upon assessment of the urine in a patient's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. This assessment finding indicates which of the following? a) The patient is receiving adequate fluid intake. b) The patient is underhydrated. c) The patient has a urinary tract infection. d) The patient is overhydrated.

If obstructed, which component of the urination system would cause peristaltic waves?

Ureters

A patient's urine is cloudy, is amber, and has an unpleasant odor. Which problem may this info indicate that requires the nurse to make a focused assessment?

Urinary Tract Infection

b (An ileal conduit is a cutaneous urinary diversion that involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of the small bowel. This separated section of the small intestine is then brought to the abdominal wall, where urine is excreted through a stoma. Such diversions are usually permanent, and the patient wears an external appliance to collect the urine, because elimination of the urine from the stoma cannot be controlled voluntarily.)

Urinary elimination from an ileal conduit can be voluntarily controlled after the stoma heals from the initial surgery. a) True b) False

An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care?

Urinary incontinence

When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? Urinary incontinence Urinary tract infection Adequate oral hydration Kidney stones

Urinary tract infection CORRECT. A urinary tract infection may develop 2 to 3 days after indwelling urinary catheter removal, and the nurse would educate the patient to be alert for signs and symptoms of such an infection.

A primary health care provider orders a urine specimen for culture and sensitivity via a straight catheter for a patient. Which should the nurse do when collecting this urine specimen?

Use a sterile specimen container.

Use of an indwelling urinary catheter leads to the loss of bladder tone. a) True b) False

d (Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination.)

Use of which the following classification of medications can cause increased urination? a) Analgesics b) Central nervous system depressants c) Stool softeners d) Cholinergic agents

Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? Change the tubing every 8 hours. Use slow, even pressure when injecting the irrigating fluid. Adhere to aseptic technique during the irrigation process. Monitor the patient's temperature every 4 hours.

Use slow, even pressure when injecting the irrigating fluid. Adhere to aseptic technique during the irrigation process. Monitor the patient's temperature every 4 hours. CORRECT. This is the correct answer. Using slow, even pressure during the instillation of fluid into the bladder helps avert bladder trauma.

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? Wear clean gloves when inserting the catheter. Inflate the balloon on the catheter before using it. Use the smallest-size catheter possible. Empty the urine by disconnecting the catheter from the collection bag.

Use the smallest-size catheter possible. CORRECT. This is the correct answer. To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the nurse would use the smallest-size catheter possible.

A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first?

Utilizing the power of suggestion by turning on the faucet and letting the water run

A nurse must obtain a clear catch urine specimen from one patient and a urine specimen via a straight catherization from another. Which intervention is not performed for both when obtaining these specimens?

Wear Sterile Gloves

d (Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition.)

What is the micturition reflex? a) The secretion of electrolytes that are harmful to the body b) The reabsorption of the substances the body wants to retain c) The process of filtration beginning with the glomerulus d) The act of bladder contraction and perceived need to void

d (A strong, offensive odor is not normally present in urine that is free of infection.)

When a client is diagnosed with a urinary tract infection, the nurse anticipates that the client's urine will be a) Light yellow with a faint ammonia odor b) Transparent with an aromatic odor c) Greenish with a strong ammonia odor d) Cloudy with an offensive odor

a (Irrigation should be avoided unless there is an obstruction to prevent infection. A closed system should be maintained using sterile technique. The smallest appropriate-sized catheter should be used.)

Which of the following accurately describes a guideline when inserting an indwelling catheter? a) Avoid irrigation unless needed to relieve an obstruction. b) Maintain an open system whenever possible. c) Use the largest appropriate-sized catheter. d) Use clean technique when inserting a catheter.

b (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 patient's bed to increase pressure in the bladder.)

Which of the following is an accurate guideline to follow if there is not an immediate flow of urine after a catheter has been inserted? a) Pull out the catheter slightly, because a drainage hole may be resting against the bladder wall. b) Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles. c) Lower the head of the patient's bed to increase pressure in the bladder area. d) Lightly apply pressure on the patient's bladder until a flow of urine is established.

a (The nurse should auscultate over the access site with the bell of the stethoscope, listening for a bruit or vibration, and palpate over the access site, feeling for a thrill or vibration. If these are not present, the physician should be notified at once. An IV should not be started in the arm with the access.)

Which of the following is an accurate step when caring for a hemodialysis access? a) Auscultate over the site with a stethoscope to listen for a bruit or vibration. b) Use the affected arm if an IV must be started to avoid impairment of both arms. c) If a thrill is not palpable and/or a bruit is not audible, assess for these signs in the other arm. d) Percuss the site to feel for a thrill or vibration.

a (The catheter is not in the bladder, so urine in the tubing is not sterile.)

Which of the following is an advantage of using a condom catheter for a male patient 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) It can be left in place for a long period of time. c) The patient can apply it himself with minimal supervision. d) A sterile urine specimen can be obtained from the drainage bag tubing.

a (The only true statement is that the largest part of the regular bedpan should be placed under the patient's buttocks. Very thin and elderly patients may prefer the fracture bedpan. Both types of bedpans can be used for either urination or defecation. A fracture bedpan can be used for any patient.)

Which of the following statements about bedpans is true? a) The largest part of a regular bedpan should be placed under the patient's buttocks. b) A regular bedpan is generally more comfortable for patients than a fracture bedpan. c) A fracture bedpan should used only for patients who have fractures of the femur or lower spine. d) A fracture pan is preferred for urination and a regular bedpan is preferred for defecation.

b (A urinal should not be left in place for extended periods of time, because pressure and irritation to the patient's skin can result.)

Which of the following statements about the use of a urinal is true? a) If nocturnal incontinence is anticipated, a urinal can be placed between the legs while the patient is asleep. b) Unless contraindicated, nurses should encourage patients to stand to use a urinal. c) Both male and female patients commonly void into a urinal in the bathroom to facilitate measurement of urinary output. d) Urinals must be replaced every 24 hours to reduce the risk of infection.

Which of the following statements should be included in the nurse's teaching plan for older adults regarding urinary elimination? a) Nocturia and urinary retention are more common in older adults. b) The kidneys become more effective in filtration with age. c) Most older adults experience an increased blood flow to the kidneys. d) Kidney function progressively increases as the body ages.

a (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.)

Which of the following statements should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? a) Boys may take longer for daytime continence than girls b) Daytime continence is usually not achieved by boys until age 5 c) Boys may walk by 1 year and should be continent by 3 years d) Incontinence after the age of 3 years is not normal

c (Pyuria, or the presence of pus in urine, is highly suggestive of a UTI. UTIs do not typically result in glycosuria or proteinuria. Similarly, a complete cessation of urine production is not associated with uncomplicated UTI.)

Which of the following terms is most closely associated with an acute urinary tract infection? a) Glycosuria b) Proteinuria c) Pyuria d) Anuria

c (Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions.)

Which type of incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions? a) Stress b) Functional c) Urge d) Overflow

a (sensing the need to do so; many physical and psychological issues can be related to this problem. Overflow incontinence is related to overdistention, or overflow, of the bladder. Causes of functional incontinence include environmental barriers, physical limitations, memory loss, and disorientation.)

Which type of incontinence is caused by pelvic floor muscle weakness? a) Stress b) Functional c) Overflow d) Urge

b (The presence of reddened meatal skin is an abnormal finding. The healthy skin should be moist and non-inflamed with no discharge present. Smegma, an accumulation of white, odorous secretions from sebaceous glands found under the labia minora in women and under the foreskin in men, is normal and is not a discharge from the urinary meatus.)

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 of the following would the nurse document as an abnormal finding? a) Moist perineal skin b) Reddened meatal skin c) Absence of discharge d) Presence of smegma

Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they

Would feel more comfortable assuming a normal voiding position.

c (Start the procedure over and attempt to place the new catheter directly above misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Never remove a catheter from the vagina and insert it in the urethra as this action can cause cross-contamination.)

You are attempting to insert a urinary catheter into a female patient's bladder and realize the catheter has been inserted into the vagina. Which of the following actions is most appropriate? a) Ask the patient to bear down until the catheter is expelled. b) Remove the catheter from the vagina and attempt to insert it into the bladder. c) Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. d) Immediately remove the catheter from the vagina, contact the primary care provider and anticipate an order for prophylactic antibiotics.

b (Size 5F to 8F is used for infants and young children. Size 8F to 12F catheters are commonly used for older children. Size 14F to 16F are usually used for adults. Size 24F is a distractor for this question.)

You are preparing to insert an indwelling urinary catheter into a 3-year-old child. Which of the following sizes of urinary catheters should you plan to use? a) 24 Fr b) 6 Fr c) 16 Fr d) 10 Fr

a nurse collects a clean-catch specimen from a client at a health care facility. which of the following statements describes a clean-catch urine sample?

a sample of urine that is considered sterile rationale: a clean-catch specimen is a sample of urine that is considered sterile. a clean-catch specimen is preferred to a randomly voided specimen. this method of collection is preferred when a urine specimen is needed during a client's menstrual cycle. a void specimen is a sample of fresh urine collected in a clean container. a catheter specimen is a sample of urine collected in a sterile environment using a catheter. a 24-hour specimen is a sample of urine collected over a 24-hour period

A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Drink your nightly glass of milk earlier in the evening." b. "Set your alarm clock to wake you every 2 hours, so you can get up to void." c. "Line your bedding with plastic sheets to protect your mattress." d. "Empty your bladder completely before going to bed."

a. "Drink your nightly glass of milk earlier in the evening."

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"

a. "When was the last time you voided?"

The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient? a. A 12-year-old female with severe abdominal trauma b. A 24-year-old male with severe genital warts around the urethra c. A 50-year-old male with recent prostatectomy d. A 75-year-old female with end-stage renal disease

a. A 12-year-old female with severe abdominal trauma

A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.

a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void.

The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice. c. Withholding all patient medications for the day. d. Asking the patient to notify the staff before and after every void.

a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice.

When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? a. Bacteria b. Casts c. Crystals d. Protein

a. Bacteria

A nurse is providing care to a patient with an indwelling catheter. Which practice indicates the nurse is following guidelines for avoiding catheter-associated urinary tract infection (CAUTI)? a. Drapes the urinary drainage tubing with no dependent loops b. Washes the drainage tube toward the meatus with soap and water c. Places the urinary drainage bag gently on the floor below the patient d. Allows the spigot to touch the receptacle when emptying the drainage bag

a. Drapes the urinary drainage tubing with no dependent loops

What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Fever and chills b. Difficulty holding in urine c. Increased blood pressure d. Abnormal blood sugar

a. Fever and chills

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL

a. Glomerular filtration rate of 20 mL/min

A nurse anticipates urodynamic testing for a patient with which symptom? a. Involuntary urine leakage b. Severe flank pain c. Presence of blood in urine d. Dysuria

a. Involuntary urine leakage

A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper.

a. Perform pelvic floor exercises.

Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective? a. Recording an output that is larger than the amount instilled b. Presence of blood clots or sediment in the drainage bag c. Reduction in discomfort from bladder distention d. Visualizing clear urinary catheter tubing

a. Recording an output that is larger than the amount instilled

Which of the following are indications for irrigating a urinary catheter? (Select all that apply.) a. Sediment occluding within the tubing b. Blood clots in the bladder following surgery c. Rupture of the catheter balloon d. Bladder infection e. Presence of renal calculi

a. Sediment occluding within the tubing b. Blood clots in the bladder following surgery d. Bladder infection

To reduce patient discomfort during closed catheter irrigation, the nurse should a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of irrigation solution at least 12 inches above the bladder.

a. Use room temperature irrigation solution.

The nurse is preparing to apply an external catheter. Which action will the nurse take? a. allow 1 to 2 inches of space between the tip of the penis and the end of the catheter b. spiral wrap the penile shaft using adhesive tape to secure the catheter c. twist the catheter before applying drainage tubing to the end of the catheter d. shave the pubic area before applying the catheter

a. allow 1 to 2 inches of space between the tip of the penis and the end of the catheter

A nurse is caring for a hospitalized patient with a urinary catheter. Which nursing action best prevents the patient from acquiring an infection? a. maintaining a closed urinary drainage system b. inserting the catheter using strict clean technique c. disconnecting and replacing the catheter drainage bag once per shift d. fully inflating the catheter's balloon according to the manufacturer's recommendation

a. maintain a closed urinary drainage system

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel? a. obtaining a midstream urine specimen b. interpreting a bladder scan result c. inserting a straight catheter d. irrigating a catheter

a. obtaining a midstream urine specimen

A nurse is caring for a patient with a continent urinary reservoir. Which action will the nurse take? a. teach the patient how to self-cath the pouch b. teach the patient how to perform kegel exercises c. teach the patient how to change the collection pouch d. teach the patient how to void using the Valsalva technique

a. teach the patient how to self-cath the pouch

A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void? a. the patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void b. the patient does not recognize the physiological signals that indicate a need to void c. the patient is lonely, and calling the nurse is under false pretenses is a way to get attention d. the patient is not drinking enough fluids to produce adequate urine output

a. the patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void

Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.) a. Fever b. Nausea and vomiting c. Headache d. Altered mental status e. Dysuria

b. Nausea and vomiting c. Headache d. Altered mental status

The nurse would question an order to insert a urinary catheter on which patient? a. A 26-year-old patient with a recent spinal cord injury at T2 b. A 30-year-old patient requiring drug screening for employment c. A 40-year-old patient undergoing bladder repair surgery d. An 86-year-old patient requiring monitoring of urinary output for renal failure

b. A 30-year-old patient requiring drug screening for employment

When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.

b. A urinary catheter.

The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient's blood? (Select all that apply.) a. Gravity b. Osmosis c. Diffusion d. Filtration

b. Osmosis c. Diffusion

The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. c. Perineal care is often neglected by nursing staff. d. Bedpans and urinals are not stored properly and transmit infection.

b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures.

Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Wearing gown, gloves, and mask for all specimen handling d. Allowing the patient adequate time and privacy to void e. Squeezing urine from diapers into a urine specimen cup f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine

b. Labeling all specimens with date, time, and initials d. Allowing the patient adequate time and privacy to void f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine

Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins

b. Maintaining fluid and electrolyte balance

When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? a. Inserting the catheter using strict clean technique b. Performing hand hygiene before and after providing perineal care c. Fully inflating the catheter's balloon according to the manufacturer's recommendation d. Disconnecting and replacing the catheter drainage bag once per shift

b. Performing hand hygiene before and after providing perineal care

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

b. Reddened irritated skin on the buttocks.

Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence

b. Risk of infection

If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra

b. Ureters

A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication

b. Utilizing the power of suggestion by turning on the faucet and letting the water run

Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they a. Are embarrassed that they will urinate on the bedding. b. Would feel more comfortable assuming a normal voiding position. c. Feel they are losing their independence by asking the nursing staff to help. d. Are worried about acquiring a urinary tract infection.

b. Would feel more comfortable assuming a normal voiding position.

The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria? a. blood in the urine b. burning upon urination c. immediate, strong desire to void d. awakes from sleep due to urge to void

b. burning upon urination

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structure, following the flow of urine? a. kidney, urethra, bladder, ureters b. kidney, ureters, bladder, urethra c. bladder, kidney, ureters, urethra d. bladder, kidney, urethra, ureters

b. kidney, ureters, bladder, urethra

The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take? a. measure bladder before the patient voids b. measure bladder within 10 minutes after the patient voids c. measure bladder with head of the bed raised to 60 degrees d. measure bladder with head of the bed raised to 90 degrees

b. measure bladder within 10 minutes after the patient voids

The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect? a. red color b. orange color c. dark amber color d. intense yellow color

b. orange color

An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leads on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plane of care? a. functional urinary incontinence b. urge urinary incontinence c. impaired skin integrity d. urinary retention

b. urge urinary incontinence

Which assessment question should the nurse ask if stress incontinence is suspected? a. "Does your bladder feel distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"

c. "Do you experience urine leakage when you cough or sneeze?"

Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? a. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." b. "I will complete my bowel prep program the night before the scan." c. "I will be anesthetized so that I lie perfectly still during the procedure." d. "I will ask the technician to play music to ease my anxiety."

c. "I will be anesthetized so that I lie perfectly still during the procedure."

A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding? a. "Since I'm taking medication, I do not need to worry about proper hygiene." b. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out." c. "My medication may discolor my urine; this should resolve once the medication is stopped." d. "I should not have sexual intercourse until the infection has resolved."

c. "My medication may discolor my urine; this should resolve once the medication is stopped."

The nurse would anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection.

c. A 56-year-old male admitted for bladder irrigation

A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

c. Assess for bladder distention.

The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? a. Dysuria b. Flank pain c. Frequency d. Fever and chills

c. Frequency

A nurse notifies the provider immediately if a patient with an indwelling catheter a. Complains of discomfort upon insertion of the catheter. b. Places the drainage bag higher than the waist while ambulating. c. Has not collected any urine in the drainage bag for 2 hours. d. Is incontinent of stool and contaminates the external portion of the catheter.

c. Has not collected any urine in the drainage bag for 2 hours.

To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Hold the labia apart while voiding into the specimen cup. d. Drink fluids 5 minutes before collecting the urine specimen.

c. Hold the labia apart while voiding into the specimen cup.

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Clear the path to the bathroom of all obstacles before bed. b. Leave the bathroom light on to illuminate a pathway. c. Limit fluid and caffeine intake before bed. d. Practice Kegel exercises to strengthen bladder muscles.

c. Limit fluid and caffeine intake before bed.

The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? a. Emptying the drainage bag every 8 hours or when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Failing to secure the catheter tubing to the patient's thigh

c. Placing the drainage bag on the side rail of the patient's bed

The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom.

c. Spinal anesthetics can temporarily disable urethral sphincters.

The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be a. Cloudy. b. Discolored. c. Sweet smelling. d. Painful.

c. Sweet smelling.

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action? a. the patient may void uncontrollably during the procedure b. local trauma sometimes promotes excessive urine incontinence c. anesthetics can decrease bladder contractility and cause urinary retention d. the patient will not interrupt the procedure by asking to go to the bathroom

c. anesthetics can decrease bladder contractility and cause urinary retention

A nurse is caring for a male patient with urinary retention. Which action should the nurse take first? a. limit fluid intake b. insert a urinary catheter c. assist to a standing position d. ask for a diuretic medication

c. assist to a standing position

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up? a. protein level of 2 mg/100ml b. urine output of 80 ml/hr c. specific gravity of 1.036 d. pH of 6.4

c. specific gravity 1.036

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 rationale: a condom catheter may be used in the care of male patients who lack voluntary control of urination. this is preferable to invasive catheterization (which presents an infection risk) and incontinence briefs (which may promote skin breakdown)

The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by a. Obtaining baseline vital signs after the start of the procedure. b. Monitoring the extremity for neurocirculatory function. c. Keeping the patient on bed rest for the prescribed time. d. Administering an antihistamine medication to the patient.

d. Administering an antihistamine medication to the patient.

When establishing a diagnosis of altered urinary elimination, the nurse should first a. Establish normal voiding patterns for the patient. b. Encourage the patient to flush kidneys by drinking excessive fluids. c. Monitor patients' voiding attempts by assisting them with every attempt. d. Discuss causes and solutions to problems related to micturition.

d. Discuss causes and solutions to problems related to micturition.

An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? a. Urinary tract infections are unavoidable in the elderly because of a weakened immune system. b. Decreasing fluid intake will decrease the amount of urine with bacteria produced. c. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection. d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? a. Renal ultrasound b. Bladder scan c. KUB x-ray d. Intravenous pyelogram

d. Intravenous pyelogram

A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Administer narcotic medications to alleviate pain. d. Monitor the patient for fever, rash, and difficulty breathing.

d. Monitor the patient for fever, rash, and difficulty breathing.

An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? a. Urinary retention b. Hesitancy c. Urgency d. Urinary incontinence

d. Urinary incontinence

A nurse is watching a nursing assistive personnel (NAP) perform a postvoid bladder scan on a female with a previous hysterectomy. What action will require the nurse to follow up? a. palpates the patient's symphysis pubis b. wipes scanner head with alcohol pad c. applies a generous amount of gel d. sets the scanner to female

d. sets the scanner to female

a client has been NPO after midnight for surgery. it is 11 AM 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 rationale: 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's 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 frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. the nurse reviews measures to follow to promote health and decrease the risk of contracting a UTI. which measure is appropriate for the client to follow?

drink two glasses of water before and after sexual intercourse rationale: 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 towards the rectum; drinking two glasses of water before and after sexual intercourse; showering rather than bathing; wearing cotton underwear; avoiding tight, constricting clothing; and drinking cranberry juice or blueberry juice daily

a nurse is caring for a client with an external condom catheter. which of the following is a guideline for applying and caring for this type of catheter?

fasten the condom securely enough to prevent leakage without constricting the blood vessels rationale: nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. this includes removing the catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. in hot and humid weather. more frequent changing may be required. in all cases, care most be take to fasten the condom securely enough to prevent leakage, yet not so tight as to constrict the blood vessels in the area. in addition, the tip of the tubing should be kept one to two inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area

a client at a healthcare facility has been diagnosed with polyuria. how would the nurse describe the client's condition in medical records?

greater than normal urinary volume rationale: 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 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 urethras catheter (straight catheter) rationale: an intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the 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; and a ballon is inflated to ensure that the catheter remains in the bladder ounce it is inserted

a nurse who is providing continence training to a client plans a trial schedule for voiding that correlates with the time when the client is usually incontinent. which of the following is the best reason for the nurse's plan of action?

it shows respect for the client's schedule rationale: during the training, the nurse plans a trial schedule for voiding that correlated with the time when the client is usually incontinent , so as to reduce the potential for accidental voiding or sustained urinary retention. this shows respect for the client's schedule. compiling a log of the client's urinary elimination pattern helps reveal the type of incontinence. setting realistic, specific, short-term goals for the client prevents self-defeating consequences. discouraging strict limitations of fluid intake ensures adequate urine volume

a client at a health care facility has been diagnosed with total urinary incontinence. how could the nurse describe the condition of the client?

loss of urine with no identifiable pattern or warning rationale: 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; whereas, urge incontinence can be described as the need to void is 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 isn't accessible

which of the following statements should be included in the nurse's teaching plan for older adults regarding urinary elimination?

nocturia and urinary retention are more common in older adults rationale: nocturia and urinary retention are more common in older adults

a nurse is performing an intermittent closed catheter irrigation on a client and realizes that the tubing was not clamped before introducing the irrigation solution. what should be the nurse's response to this situation?

repeat irrigation rationale: if the tubing wasn't 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

a women 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 get tense rationale: a person's muscles may become so tense that relaxation of the perineal muscles doesn't occur, and voiding is inhibited

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

stress incontinence rationale: stress incontinence is caused by pelvic floor muscle weakness. urge incontinence is the inability to suppress urination after seeing the need to do so; many physical and psychological issues can be related to this problem. overflow incontinence is related to over distention, or overflow, of the bladder. causes of functional incontinence include environmental barriers, physical limitations, memory loss, and disorientation

a nurse is caring for a client who has an infant age 4 months. the client informs the nurse that she has been experiencing sudden loss of urine whenever she laughs; this is causing embarrassment to her. which type of urinary incontinence is this client experiencing?

stress incontinence rationale: the nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to childbirth. the nurse shouldn't document the condition as reflex incontinence, urge incontinence, or functional incontinence. reflex incontinence is caused by damage to motor and sensory tracts in the lower spinal cord secondary to trauma. urge incontinence is caused by bladder irritation secondary to infection. functional incontinence is caused by impaired mobility, impaired cognition, or an inability to communicate

a nurse accessing the access site of a hemodialysis catheter cannot palpate a thrill or hear a bruit. what is the most likely cause of this emergency situation?

the access may be clotting off rationale: if a thrill isn't palpable and/or bruit isn't audible, the nurse should notify the primary care provider immediately. the thrill and bruit are cause by arterial blood flowing into the vein. if these signs aren't present, the access may be clotting off

the nurse is providing teaching to a client who is being discharged home with an indwelling catheter in place. what information is important for the nurse to discuss with the client?

the catheter can be connected to a smaller leg bag for ambulation rationale: educational points related to an indwelling catheter include instructions on connecting the catheter to a smaller leg bag for ambulation; maintaining adequate fluid; keeping the catheter free of kinks (avoid clamping the catheter tubing); emptying the drainage bag at regular intervals; and avoiding a full drainage bag that may lead to reflux of urine

a nurse is collecting a routine urinalysis on a client presenting to the emergency room with abdominal pain. which of the following are true regarding this specimen?

the nurse will obtain a nonsterile specimen and send it to the lab rationale: a sterile urine specimen isn't required for a routine urinalysis. obtain and label the specimen and send it to the laboratory for examination. don't leave the urine standing at room temperature for a long period of time before sending it to the laboratory, because this may alter both the appearance and chemistry of the urine

the nursing student who is learning skills during campus lab identifies which of the following statements about bedpans to be true?

the rounded shelf of a regular bedpan should be placed under the client's buttocks rationale: the only true statement is that the rounded shell of the regular bedpan should be placed under the client's buttocks. very thin and older adult clients may prefer the fracture bedpan. both types of bedpans can be used for either urination or dedication. a fracture bedpan can be used for any client

the nurse should instruct the female client who has experienced two urinary tract infections within the past year to do what?

void following sexual intercourse rationale: factors that increase the incidence of urinary tract infections include incorrect wiping of the anal area after bowel elimination; sexual intercourse, which can bring perineal microorganisms into closer contact with the uretheral meatus; and any procedures that places and object in the urethra or bladder for diagnostic procedures or therapeutic reasons

a sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. how should the nurse obtain this specimen?

withdraw several millimeters of urine from the port on the collection tubing, using a syringe and needle rationale: when it's 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. a specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. a client's catheter wouldn't be removed for the sole purpose of obtaining a urine specimen

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