GI- urinary elimination

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response? his is extremely abnormal. You will need to see your son's pediatrician." "I would only worry about this if you were raising a daughter." "It would be appropriate to place your son in incontinence undergarments." "Let's review the types of fluids that your child drinks in the morning."

"Let's review the types of fluids that your child drinks in the morning." Bladder irritants such as caffeine can cause urge incontinence; it is appropriate to determine whether the child is consuming fluids that contain caffeine. The child's urge incontinence is not extremely abnormal, and this physiological response is not related to gender. It is too soon to refer the client to the health care provider without taking a history, and it is impractical to simply recommend incontinence undergarments.

The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options. 1. Provide instruction to the client. 2.Clean the area surrounding the urinary meatus with the provided cloth. 5. Void a small amount into toilet or bedpan. 6. Void into the provided collection device. 3. Secure the lid on the specimen container. 4. Submit collected specimen to the health care professional

1, 2,5, 6,3,4 1. Provide instruction to the client. 2.Clean the area surrounding the urinary meatus with the provided cloth. 5. Void a small amount into toilet or bedpan. 6. Void into the provided collection device. 3. Secure the lid on the specimen container. 4. Submit collected specimen to the health care professional

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. 1. Clean each labial fold, then the area directly over the meatus. 2. Insert the lubricated catheter into the urethra. 3. Inflate the balloon with the correct amount of sterile saline. 4. Advance the catheter until there is a return of urine. 5. Discard used supplies

1. Clean each labial fold, then the area directly over the meatus. 2. Insert the lubricated catheter into the urethra. 4. Advance the catheter until there is a return of urine. 3. Inflate the balloon with the correct amount of sterile saline. 5. used supplies

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? 24-hour specimen clean-catch specimen random specimen intermittent specimen

24-hour specimen A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? 24-hour specimen clean-catch specimen random specimen intermittent specimen

24-hour specimen A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a theres microorganisms. . Random urine specimen collection is used when sterile urine is not required.

Which client should the nurse monitor most closely for signs of urinary retention? A client receiving corticosteroids for acute inflammation A client who suffered pelvic muscle damage in childbirth 6 months ago A client who has been diagnosed with early stage Alzheimer's disease A client with an enlarged prostate

A client with an enlarged prostate Urinary retention is often related to an enlarging prostate gland. Pelvic damage more commonly leads to incontinence, not retention. Corticosteroids are not associated with urinary retention. Cognitive deficits are more likely to result in incontinence than urinary retention.

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action? Gather equipment and supplies. Assess urine characteristics. Explain the procedure to the client. Check electronic health record for medical order

Check electronic health record for medical order The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after it has been confirmed that an order for irrigation exists.

The nurse is changing a stoma appliance on an ileal conduit. Which nursing action is recommended procedure? Select all that apply. A. Gently remove the appliance, starting at the top and keeping the abdominal skin taut. B. Remove appliance faceplate by pulling appliance from skin rather than pushing. C. Apply a silicone-based adhesive remover by spraying or wiping as needed. D. Clean skin around stoma with alcohol on a gauze pad. E. Make sure skin around stoma is thoroughly dry by patting it dry. F. Apply faceplate by using firm, even pressure for approximately 60 seconds.

A, C, E, The nurse would gently remove the appliance, starting at the top and keeping the abdominal skin taut. This method would prevent excessive damage to skin and tissue of the client. The nurse would apply a silicone-based adhesive remover by spraying or wiping as needed. The adhesive remover helps to prevent skin and tissue damage. The nurse would make sure skin around the stoma is thoroughly dry by patting it dry. Moist skin does not hold adhesives well, possibly causing skin and tissue damage. The nurse would not remove the appliance faceplate by pulling the appliance from the skin rather than pushing. The nurse would not clean the skin around the stoma with alcohol. Alcohol is drying to the skin, possibly causing skin or tissue damage. The nurse would not hold the faceplate firmly in place for 60 seconds when placing it. Pressure for 30 seconds is sufficient.

A client could experience increased urination when using which classification of medication? Cholinergic agents Analgesic medications Central nervous system depressants Stool softeners

Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination. Analgesics act to relieve pain. Central nervous system depressants are medicines that include sedatives, tranquilizers, and hypnotics. These drugs can slow brain activity, making them useful for treating anxiety, panic, acute stress reactions, and sleep disorders. Stool softeners makes bowel movements softer and easier to pass.

The nurse has inserted a client's urinary catheter as ordered, but there has been no immediate flow of urine. What is the nurse's most appropriate action? A. Have the client take a deep breath to relax the perineal and abdominal muscles. B. Advance the catheter slightly, because a drainage hole may be resting against the bladder wall. C. Lower the head of the client's bed to increase pressure in the bladder area. D. Leave the catheter in place and reassess in 30 minutes.

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

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? a. Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. b. Administer an IV on the arm high above the access site. c. Perform venipuncture below the access site to obtain a blood sample for laboratory testing. d. Measure the client's blood pressure on the arm above the access site.

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.

The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse will perform what assessment specifically associated with the development of this condition in the older adult? Temperature assessment Assessment for dysuria Cognitive assessment Assessment for nausea

Cognitive assessment Symptoms of UTI are different in the older adult, especially if the immune system is depressed. Rather than experiencing painful urination and a high fever, the older adult may become acutely confused. Nausea is not normally associated with UTI's.

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? Monitor vital signs Contact the health care provider Encourage fluids Instruct on proper wiping technique

Contact the health care provider The term pyuria refers to the presence of pus in the urine. The nurse should first contact the health care provider, as antibiotic therapy may be necessary. Encouraging fluids, instruction on wiping technique and monitoring vital signs will follow.

A client is reporting bladder urgency. The nurse will assess which of the following? Blood pressure Body weight Caffeine intake Use of vitamin supplements

Caffeine intake Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts. Blood pressure changes do not typically cause urgency, nor do most common vitamin supplements. Body weight affects urinary function, as with all body systems, but is not specifically linked to urgency.

Which is true regarding the normal urination? Catheterized clients should drain a minimum of 30 mL of urine per hour. In adults, the average amount of urine per void is 500 mL. Urinary output does not vary all that much between adults and children. In adults, the amount of urine voided typically does not depend on fluid intake and losses.

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

Which is true regarding the normal urination? Catheterized clients should drain a minimum of 30 mL of urine per hour. In adults, the average amount of urine per void is 500 mL. Urinary output does not vary all that much between adults and children. In adults, the amount of urine voided typically does not depend on fluid intake and losses.

Catheterized clients should drain a minimum of 30 mL of urine per hour. Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.

The nurse has placed a urine collection bag on an infant. How often should the nurse check the bag to see if the infant has voided? Every 15 minutes Every 30 minutes Every 45 minutes Every 60 minutes

Every 15 minutes The nurse should check the bag every 15 minutes. An infant does not have voluntary control over the bladder, so voiding occurs when the bladder is full. Checking the bag too frequently is not necessary. If the length of time is too long, the bag may overfill with urine and become unattached. The nurse should make sure the bag is secured in place.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? Loosen the internal muscles used to prevent or interrupt urination. Keep muscles contracted for at least 10 seconds. Relax muscles for at least 5 minutes between Kegels. Perform these exercises two times daily for a week.

Keep muscles contracted for at least 10 seconds.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? Calculating the flow rate of urinary output Monitoring the characteristics of the urinary output Assessing PVR using a bladder scanner Palpating the client's bladder region

Monitoring the characteristics of the urinary output The effectiveness of therapy is determined by the urine characteristics. On completion of the therapy with continuous bladder irrigation, the client should exhibit urine that is clear, without evidence of clots or debris. The client will have no PVR during therapy. Palpation of the bladder region and calculation of a particular outflow rate do not determine the success or failure of therapy.

A client is suspected of having a disease process affecting the basic functional unit of the kidney. Which structure is most likely involved? Glomerulus Bowman's capsule Loop of Henle Nephron

Nephron 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 nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? Position the client in a supine position. Administer a diuretic, as ordered. Have the client rest for 15 minutes before the assessment. Assess the client's need for analgesia.

Position the client in a supine position. Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of what? Protein Calculi Pus Casts

Pus

Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. A, Contact the health care provider to ask for an order for catheter discontinuation. B, Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). C, Perform, or allow client to perform, perineal hygiene at least once daily. D, Ensure that the drainage bag is above the level of the bladder at all times. E, Discontinue to catheter and report this to the healthcare provider.

Q Contact the health care provider to ask for an order for catheter discontinuation. C Perform, or allow client to perform, perineal hygiene at least once daily.

Which urinary care teaching will the nurse provide to a young adult female client? a, Wipe from the back to the front. b, Refrain from douching unless ordered by a health care provider. c, If you do not feel like voiding, still strain to make sure the bladder is empty. d, Drink water more frequently in the morning and evening to facilitate hydration.

Refrain from douching unless ordered by a health care provider. Douching is not recommended unless ordered by the health care provider. Female clients should be taught to wipe from the urinary area towards the rectum to decrease the risk for introducing pathogens into the urethra. Straining is not appropriate. Water should be consumed throughout the day, not just in the morning and evening.

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client? Encouraging the client to stay close to home Fluid restriction Indwelling catheterization Regular toileting routine

Regular toileting routine The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.

The nurse is caring for a client who has been experiencing difficulty voiding in the eight hours since her vaginal birth. What information should be provided to the client? The birth can cause perineal swelling. A neurogenic bladder results from local anesthesia A urinary tract infection can result from the birth process Catheterization is likely necessary for five to seven days

The birth can cause perineal swelling. Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period. The effects of anesthesia do not constitute a neurogenic bladder. Catheterization may be necessary in the short term, but 5 to 7 days would normally be excessive and create a risk for infection. Birth does not normally cause a UTI, whose effects would not evident at this early stage postpartum.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions? The client drinks eight 8-oz glasses of cranberry juice daily. The client soaks in the bathtub daily for perineal care. Since the client is symptom-free, she no longer takes the prescribed antibiotics. The client drinks two glasses of water before and after sexual intercourse.

The client drinks two glasses of water before and after sexual intercourse. Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal? The client was treated for kidney stones a few months earlier. The client has a history of benign prostatic hyperplasia (BPH; prostate enlargement). The client has had urinary catheters in place repeatedly during previous admissions. The client is acutely confused and has been diagnosed with delirium.

The client is acutely confused and has been diagnosed with delirium.

A client's BUN test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.

The client is dehydrated. The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions? The client may bathe rather than shower, provided the site is covered with gauze. A dressing should always be worn over the site to avoid leaking. Sterile technique must be observed by the client in the home setting. The client should avoid wearing tight clothes or belts near the site.

The client should avoid wearing tight clothes or belts near the site. Clients should avoid baths and public pools as well as wearing tight clothes and belts around the exit site. Once the site is healed, some health care providers do not require clients to wear a dressing unless the site is leaking. Clean technique is sometimes allowed in the home.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client? a. This urinary diversion is only temporary. b. The client will need to change the urinary pouch every 4 hours. c. The client will have to wear an external appliance to collect urine. d. Urination can be voluntarily controlled after the stoma heals from the initial surgery

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

A nurse uses a portable bladder ultrasound device to assess bladder volume for a client who is unable to void. Which statement accurately details information needed to interpret the results? The scan is contraindicated for female clients who have had a hysterectomy. The device must be programmed for the biological sex of the client by pushing the correct button on the device. Three separate readings should be obtained over 1 hour and the postvoid residual (PVR) averaged. A PVR of 450 mL is often recommended as the guideline for catheterization.

The device must be programmed for the biological sex of the client by pushing the correct button on the device. The device must be programmed for the biological sex of the client by pushing the correct button on the device. If a female client has had a hysterectomy, the male button is pushed. A PVR of >150 mL is often recommended as the guideline for catheterization, because residual urine volumes of >150 mL have been associated with the development of urinary tract infections. It is not necessary to obtain three independent readings.

The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted? The novice nurse asks the client to take a deep breath when resistance was met during insertion of the catheter. The novice nurse selects an 18 French Foley catheter to insert. The novice nurse places a trash receptacle within easy reach. The novice nurse assists the client to a dorsal recumbent position with knees flexed, feet about 2 ft (0.6 m) apart.

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

The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, dark amber strongly aromatic, amber

The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine. Urine is normally light yellow and clear. Dark amber urine that is strongly aromatic could indicate dehydration, but would not create the symptoms noted.

A nurse has just removed an indwelling catheter from a client. Which common complications of urinary function should the nurse monitor for in the client, after removal of an indwelling catheter? Select all that apply. Urinary incontinence Difficulty voiding Urinary retention Increased volume of urine output Burning or irritation while voiding Urinary frequency

Urinary incontinence Difficulty voiding Urinary retention Burning or irritation while voiding The client may experience burning or irritation the first few times he or she voids after removal, due to urethral irritation. If the catheter was in place for more than a few days, decreased bladder muscle tone and swelling of the urethra may cause the client to experience difficulty voiding or an inability to void. Accidents are possible until the client establishes voluntary control of the bladder. The nurse should monitor the client for urinary retention. Urinary frequency and increased volume of urine output are not complications of urinary function following removal of an indwelling catheter.

The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed? Blood urea nitrogen (BUN) - 7 mg/dL (19.6 mmol/L) Urine culture sensitivity - 100,000/mL Hemoglobin - 16 g/dL Magnesium - 2.5 mEq/L (2.5 mmol/L)

Urine culture sensitivity - 100,000/mL 100,000 organisms per milliliter in a urine culture and sensitivity specimen is positive of a urinary tract infection. BUN, hemoglobin, and magnesium are all within the normal ranges.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? a. Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. b. Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. c. Perform hand hygiene between cleansing the woman's labia and inserting the catheter. d. Insert the catheter with her left hand while supporting the woman with her right hand.

Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately? A. Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container. B. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. C. Obtained urine specimen from urinary drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port. D. Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure.

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. Which information is essential for the nurse to review with the client as a strategy to decrease future risk of UTI? a. Voiding before and after sexual intercourse b. Wiping the perineal area from the rectal area to the urethra c. Taking baths instead of showers d. Wearing satin or silk underwear that hugs the skin tightly

Voiding before and after sexual intercourse Measures to decrease the risk for a UTI include drinking ten 8-ounce glasses of water daily; observing for signs and symptoms of a UTI; drying the perineal from the urethra toward the rectum; voiding before and after sexual intercourse; showering rather than bathing; wearing cotton underwear; avoiding tight, constricting clothing; and drinking cranberry or blueberry juice daily.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority? Using an appropriate measuring container Wearing gloves when handling the urine Measuring the urine container at eye level Noting the color and clarity of the urine

Wearing gloves when handling the urine All of these interventions would be important to ensure safety in handling the client's urine and obtaining an accurate output. However, safety with handling body fluids would be a priority for the nurse to decrease risk of exposure to pathogens or blood that may be in the client's urine.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate? a. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. b. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. c. Ask the client to bear down until the catheter is expelled. d. Remove the catheter from the vagina and attempt to insert it into the bladder.

a Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Leaving the catheter in place as a marker assists in the correct placement of the second catheter into the bladder. It is not necessary to contact the health care provider. The vagina is not sterile, so insertion of a sterile catheter poses little risk for infection. Asking the client to bear down is not necessary because the catheter is not typically completely inserted. Removing the catheter from the vagina and attempting to insert it into the bladder will cause cross-contamination.

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem? a. Discuss the use of protective undergarments to avoid embarrassment from incontinence. b.Encourage the client to confide in family members and tell them about the accidents. c. Inform the client that this is not normal and make a referral to a urologist. d. Tell the client that this happens to all people when they get older.

a. Discuss the use of protective undergarments to avoid embarrassment from incontinence. The nurse will promote the client's self-esteem by openly discussing adult undergarments. The client has no other health problems, and can benefit by learning how to self-manage this concern. Encouraging the client to tell family members does not support the client's desire to refrain from telling others about this issue. The client does not need referral to a urologist at this time. Reassuring the client that others have this concern is nontherapeutic and does not directly meet the client's concern.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? a. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. b. The client can apply it himself with minimal supervision. c. It can be left in place for a long period of time. d. A sterile urine specimen can be obtained from the drainage bag tubing.

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

A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen? a. Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. b. Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag. c. Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. d. Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic.

a. Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens and aseptic technique. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen. Collection of a specimen does not need to happen in the morning or after a diuretic.

The client is a new client in the outpatient wellness clinic. The client reports frequent urinary incontinence of recent onset. The nurse reviews the client's list of medications. Which medication classification will the nurse review with the client to determine when the prescription was started? antihypertensive nonsteroidal anti-inflammatory drug (NSAID) H2-receptor antagonist calcium supplement

antihypertensive

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? anuria oliguria nocturia urinary retention

anuria Absence of urine for a 24-hour period reflects anuria.

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

b. Boys may take longer for daytime continence than girls. 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.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? a.Moist perineal skin b.Reddened perineal skin c. Presence of smegma d.Absence of discharge

b. Reddened perineal skin The presence of reddened perineal skin is an abnormal finding. The healthy skin should be moist and noninflamed 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 considered a normal finding.

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend? fracture pan bedside commode bed pan regular bathroom

bedside commode

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next? a. Have the client drink 8 ounces of water every 15 minutes for 1 hour. b. Wipe off some of the ultrasound gel and rescan. c. Ensure proper positioning of the scanner head and rescan. .d. Place the client on either side and rescan.

c. Ensure proper positioning of the scanner head and rescan. The scanner head should be repositioned, and the bladder should be rescanned before assuming that the bladder is truly empty. Additional ultrasound gel may need to be added for the scanner to work properly. If the bladder is truly distended, the client may become more uncomfortable from drinking additional water. The best position for bladder scanning is supine.

A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? a, remove the catheter every 8 hours, or more often in humid weather. b. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application. c. Fasten the condom securely enough to prevent leakage without constricting blood flow. d. Ensure the tip of the tubing is touching the tip of the client's penis.

c. Fasten the condom securely enough to prevent leakage without constricting blood flow In addition, the tip of the tubing should be kept 1 to 2 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area..

iA nurse is caring for a client who has urinary incontinence associated with a flaccid neurogenic bladder. Drag words from the choices below to fill in each blank in the following sentence. The nurse will implement _______because the client has ___________urinary incontinence.. Intervention (1st blank) a. Kegel exercises b. excellent skin care c. in-and-out catheterization d. . a timed voiding schedule e. routine toileting Type of Incontinence (2nd blank) 1. reflex 2. urge 3. functional 4. stress 5. total

c. in-and-out catheterization 1. reflex The client has the type of injury that can result in reflex urinary incontinence. With this type of urinary dysfunction, it is necessary to perform in-and-out catheterization at regular intervals. Medications may also be prescribed to relax the sphincters. A flaccid neurogenic bladder can cause involuntary incontinence associated with a specific bladder volume that can occur at slightly predictable intervals. Other causes may include spinal cord injury, brain tumor, or a cerebrovascular accident. When the volume of urine reaches a certain point it overcomes the sphincter, this is known as reflex urinary incontinence. A timed voiding schedule is used for those with urge urinary incontinence. This type of incontinence is associated with an overactive detrusor muscle, bladder dysfunction, or the affects of diuretics, caffeine, or alcohol. Kegel exercises are used to reduce the negative urinary effects associated with stress incontinence. Stress incontinence is caused by increased or high abdominal pressure. It can also be a complication associated with prostate cancer. Routine toileting can either be used with functional or total urinary incontinence. The functional type of incontinence is associated with altered environment combined with physiological deficits such as cognition, neurovascular or mobility. Excellent skin care is a necessary whenever a client has total urinary incontinence that keeps the perineal skin moist at most times. This type of incontinence can be caused by some form of impairment to the spinal cord or as a result of severe cognitive deficits.

The nurse has received an order to remove a client's indwelling urinary catheter. Which actions are appropriate when carrying out this order? Select all that apply. a. the nurse may delegate this task to unlicensed assistive personnel (UAP). b. Strict aseptic technique must be used when removing the client's catheter. c. nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). d. The nurse should remove the water from the balloon by withdrawing it with a syringe. e. Limit the client's fluid intake for 2 to 4 hours prior to removal.

c. nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). d. The nurse should remove the water from the balloon by withdrawing it with a syringe. Catheter removal can be delegated to an LPN/LVN but not to UAP. Clean, not aseptic, technique is used and there is no need to limit fluids prior to removal. A syringe must be used to deflate the balloon prior to removal.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? a. checking that the client has signed a consent form for the procedure b. explaining to the client that the procedure will be painful c. maintaining the client without liquids before the procedure d. inserting a Foley catheter the morning of the procedure

checking that the client has signed a consent form for the procedure The client would sign a consent form for the procedure since it is invasive. This would be completed by the procedural health care provider after explaining the purpose, risks, and benefits of the procedure. The will check that this consent is signed before the procedure beings. The client does not need to have fluids withheld nor have a catheter inserted for this procedure. The procedure is usually painless, so the client would not be told to expect pain as a normal part of the procedure.

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? dehydration hypovolemia balanced fluids kidney injury

dehydration The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The symptoms are not associated with hypovolemia, balanced fluids, nor kidney injury.

A client reports frequently experiencing urine loss when moving from the wheelchair to bed. Which type of incontinence does the nurse anticipate? urge total reflex functional

functional Functional incontinence takes place when attempting to overcome obstacles, such as transferring from the wheelchair to the bed. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.

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? indwelling urethral catheter intermittent urethral catheter Foley catheter retention catheter

intermittent urethral catheter

A client at a health care facility is being treated for cancer of the bladder. The health care provider uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion inability to control either urinary or bowel elimination hygiene measures used to keep meatus and adjacent area of the catheter clean use of a catheter to collect urine in a sterile environment one or both of the ureters are surgically implanted elsewhere

one or both of the ureters are surgically implanted elsewhere

A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? urge reflect stress total

stress Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Other types of incontinence have different causative factors.

The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, colorless strongly aromatic, dark amber

strongly aromatic, dark amber The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.