urinary 2

The parent of a 5-year-old child tells the nurse that on two occasions their child has lost control of urination when they had to wait to go to the bathroom at school. What is the appropriate nursing response?

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

The nurse is caring for a client who informs the nurse that it is difficult to void when experiencing stress, and asks why this happens. Which response by the nurse is appropriate?

"Stress causes the muscles to become tense." Explanation: Stress can interfere with the ability to relax the perineal muscles and the external urethral sphincter. When this happens, the client may feel an urge to void, but emptying the bladder completely becomes difficult or impossible. Needing privacy to void relates back to stress from perceived embarrassment from the need to void, which enforces the proper answer of stress affecting the perineal muscles. There is not enough information present within the scenario to point to the possibility of a neurologic condition or medications taken by the client.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

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

The nurse is preparing to insert an indwelling urinary catheter into a 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.

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

A nurse has been asked to speak about health promotion topics for a group of women older than 40 years of age. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the group?

Contract the pubic muscles for 3 seconds, then relax. Explanation: Pelvic floor muscle (Kegel) exercises, strengthen the pubococcygeal muscles and effectively promote urinary control. The nurse should inform the women to locate the muscles used to start and stop urinating. Then contract those muscles and relax them repeatedly. Strengthening the abdominal muscles will not help with urinary control. Squatting, jumping, and performing leg lifts will help to strengthen the quadriceps and hamstrings.

A 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?

Encourage fluid intake. Explanation: 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 client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. Which next step should the nurse implement?

Losing urine when a toilet is not readily available, urinating more than 8 times in a 24 hour period, and experiencing accidental loss of urine with urgency reflect urge urinary incontinence. The other findings do not reflect assessment data associated with urge urinary incontinence.

A nurse is caring for a client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action?

Many clients find it embarrassing or degrading to use a bedpan. Explanation: Many clients find it difficult and embarrassing to use the bedpan. The nurse should be aware of this fact and approach the client with dignity and professionalism. Bedpan use is not associated with UTIs and bedpans may be used for defecation. The bed should be raised to a comfortable working height for the caregiver to prevent back injury. After removing the bedpan, the nurse would then lower the bed to its lowest position.

While providing care to a client admitted to the health care facility, the client states that they have "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?

Reddened perineal skin Explanation: 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 females and under the foreskin in males) is considered a normal finding.

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence?

Stress Explanation: Stress incontinence is caused by pelvic floor muscle weakness or urethral hypermobility. Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contraction. Overflow incontinence occurs when the bladder muscle distends and urine is forced out. Functional incontinence occurs when a physical or psychological impairment impedes continence despite a competent urinary system.

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?

The client has an enlarged prostate. Explanation: Enlargement of the prostate gland is commonly seen in males over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.

A 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?

The client will have to wear an external appliance to collect urine. Explanation: An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

The client will have to wear an external appliance to collect urine. Explanation: An ileal conduit involves a surgical resection of the small intestine, with transplantation of the ureters to the isolated segment of small bowel. Such diversions are usually permanent, and the client wears an external appliance to collect the urine because urine elimination from the stoma cannot be controlled voluntarily. Appliances are usually changed every 3 to 7 days, although they could be changed more often.

The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted?

The novice nurse asks the client to urinate before palpating the bladder. Explanation: The urinary bladder cannot be palpated when empty, so the client should not urinate before the nurse palpates or percusses it. During data collection, the client should be asked—before the bladder is palpated—when the last voiding occurred. The height of the edge of the bladder should be measured above the symphysis pubis. The lower abdominal wall during an urinary bladder assessment is observed for any swelling.

The nurse is caring for a client with a Foley catheter in place who has a prescription for a sterile urine specimen for culture and sensitivity. The nurse implements which techniques to obtain the prescribed urine specimen? Select all that apply.

The nurse uses a syringe to withdraw urine from the port. The nurse dons clean gloves and cleanses the port with aseptic solution. When collecting a sterile urine specimen from a Foley catheter, the nurse wears clean gloves, cleans the port with an aseptic solution, and withdraws the specimen from the port with a syringe. The specimen should not be taken from the collecting bag because it may not be fresh and could result in an inaccurate analysis. The catheter should not be disconnected in order to prevent bacteria from entering the urinary system. If urine is not present in the tube, the tube may be clamped, but not to exceed 30 minutes.

The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence?

Total incontinence Explanation: Total incontinence may be the result of surgery, trauma, or physical malformation; the client has continuous and unpredictable loss of urine. Stress incontinence is related to an increase in intra-abdominal pressure and commonly occurs during activities such as coughing and sneezing. Overflow incontinence is associated with overdistention and overflow of the bladder, whereby the signal to empty the bladder is lost, the bladder fills, and the client dribbles urine. Functional incontinence occurs because the client is unable to reach the toilet.

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood Explanation: A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine?

blood Explanation: A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.

The health care provider notifies a client of a diagnosis of glycosuria. Which assessment information will the nurse obtain from the client next?

blood sugar Explanation: Glycosuria is a condition that describes the finding of glucose in the urine. The next step is to obtain a fingerstick for blood sugar (glucose) level for a possible cause of the glycosuria. Vital signs are a baseline indicator of any illness or injury. Intake and output may be important going forward, but the diagnosis directs the next action as obtaining a blood sugar level.

A client is reporting bladder urgency. Which will the nurse assess?

caffeine intake Explanation: 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.

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy Explanation: The client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine. Other answers are incorrect.

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 Explanation: 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 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 urethral catheter Explanation: An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted.

Which assessment data, collected by the nurse, indicates that a client may be assigned the nursing concern of urge urinary incontinence? Select all that apply.

loses urine when a toilet is not readily available urinates 20 times in 24 hours experiences accidental loss of urine when there is an urgent need to urinate

A 70-year-old client who has four children and six grandchildren states that they "wet" themself when they sneeze or laugh. They report that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?

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

A client reports to the nurse that after delivering an infant, they lose small amounts of urine each time they sneeze or laugh hard. Which type of incontinence does the nurse anticipate

stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.