204 PrepU Craven ch. 32: Urinary Elimination

A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first?

clean each side of the meatus with a separate wipe A clean-catch specimen is collected in mid-stream. The nurse will first instruct to clean each side of the urinary meatus, release a small amount of urine, catch a sample, and then complete voiding.

A nurse is conducting a health history interview for an office client who is having problems with urinary control. What would be an appropriate interview question to collect further data?

"how have you handled this problem?" When a client reports a problem with voiding, explore its duration, severity, and precipitating factors. Note the client's perception of the problem and what the client does to handle the problem (self-care behaviors).

A nurse is preparing to catheterize a female client with an overdistended bladder. Which action should the nurse take?

prepare for a rush of a large amount of urine The nurse should prepare for a rush of a large amount of urine when the bladder has been distended. There is no need for more than one catheter. An indwelling catheter should be inserted for short-term use to prevent further distention.

A nurse is caring for older adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment?

Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. The diminished ability of the kidneys to concentrate urine may result in nocturia (urination during the night). Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control and the ability to reach a toilet in time. Individuals who view themselves as old, powerless, and neglected may cease to value voluntary control over urination, and simply find toileting too much bother no matter what the setting. Incontinence may be the result.

The nurse is assessing a client with a urinary sheath catheter. After removing the catheter, the nurse observes a break in skin integrity on the penis. What actions by the nurse would be appropriate at this time? Select all that apply.

Do not reapply the urinary sheath Allow the skin to be open to air as much as possible Arrange for a consult with a wound nurse If the nurse finds a break in skin integrity when assessing the client's penis, the should not reapply the external urinary sheath. The nurse should allow the skin to be open to air as much as possible. If the facility has a wound, ostomy, and continence nurse, a consult should be arranged. An indwelling catheter should be used as a last resort due to the increased risk of urinary tract infection.

The nursing assistant reports that a client on furosemide has voided 2000 mL in a 24-hour period. What is the appropriate nursing action?

Document the finding as normal. Voiding 500-3000 mL/day is considered normal. The nurse should simply document the finding. The other actions are not necessary.

The nurse is changing a stoma appliance on an ileal conduit. Which nursing action is recommended procedure? Select all that apply.

Gently remove the appliance, starting at the top and keeping the abdominal skin taut. Apply a silicone-based adhesive remover by spraying or wiping as needed. Make sure skin around stoma is thoroughly dry by patting it dry. 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 has been taught how to do Kegel exercises. What statement by the client indicates a need for further information?

I will contract the muscles in my abdomen and thighs Kegel exercises, or pelvic floor muscle training, are used to tone and strengthen the muscles that support the bladder. They can improve voluntary control of urination and thus improve or eliminate stress incontinence. The muscles to contract are the same ones used to stop urination midstream or control defecation. The client should not contract the muscles of the abdomen, inner thigh, or buttocks while doing Kegel exercises.

A nurse is collecting a urine specimen for urinalysis. Which factors should the nurse consider when performing this procedure? Select all that apply.

Sterile urine specimens may be obtained by catheterizing the client's bladder. Strict aseptic technique must be used when collecting and handling urine specimens. A clean-catch specimen of urine may be collected in midstream. The nurse would realize that a sterile urine specimen must be obtained by catheterizing the client's bladder. The nurse would use strict aseptic technique when collecting and handling urine specimens. The nurse would realize that a clean-catch specimen of urine would be collected midstream. The nurse would realize that a sterile specimen is not required for a routine urinalysis. The nurse would realize that a menstruating woman can give a specimen for urinalysis, but this fact should be documented on the lab slip. The nurse would realize that urine cannot be left at room temperature for a 24-hour period before being sent to the laboratory.

A nurse is assessing the freshly voided urine of a client. What characteristics of the urine would indicate a urinary problem? Select all that apply.

The urine smells like ammonia. There is pus in the urine. The urine is cloudy. The urine specimen that would indicate a urinary problem would possibly smell like ammonia, have pus visible in the sample, and be cloudy in nature. A normal urine sample would be amber colored, translucent, and have a pH around 6.0.

The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include?

Tighten the internal muscles used to prevent or interrupt urination Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen three to four times daily for 2 weeks to 1 month. The client should not be instructed to keep muscles contracted for at least 30 seconds, relax muscles for at least 1 minute between exercises, nor perform these exercises 10 times daily for 1 month.

The nurse is preparing to place a Foley catheter for a female client who will soon have surgery. Into what position will the nurse place the client?

dorsal recumbent The appropriate position for a female client who will have a Foley catheter placed is the dorsal recumbent position. Other answers are incorrect.

A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample?

a sample of urine that is considered sterile 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 preparing to remove a Foley catheter and attaches a syringe to the balloon inflation tube to deflate it. Which action would be most appropriate for the nurse to do to deflate the balloon?

allow the syringe to fill on its own When deflating the balloon of a Foley catheter, the nurse attaches the syringe to the balloon inflation tube and allows the syringe to fill with fluid from the balloon. Quick manual aspiration of fluid from the balloon with a syringe can cause ridges in the balloon; these can cause trauma to the urethra when the catheter is withdrawn. Instilling air would further increase the balloon, possibly causing it to rupture. Removing the plunger to allow fluid to drain would be inappropriate.

Which scenario does not illustrate a normal lifespan variant regarding urination?

an 8-year-old is continent during the day but is incontinent 2 times during the night By the age of 5, children should be continent both during the day and the night. Although most children in North America achieve daytime continence by 3 years of age, some can take a bit longer. Most children will achieve daytime urinary control by 3 to 4 years of age. The first voiding may be slightly pink-tinged. This is caused by uric acid crystals being excreted. School-age children should achieve urinary elimination habits that are similar to adults. This frequency and color are very normal.

A nurse has received an order to insert a urinary catheter into a female client. In preparation, the nurse asks if she has ever had an indwelling catheter and, if so, why and for how long. The nurse has performed which action?

assessed the possibility that the client has urethral strictures The nurse has assessed the possibility of urethral strictures, which may make catheter insertion more difficult. This does not relate directly to the client's risk for UTIs or bleeding during insertion. The catheter size is not chosen on this basis.

What accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter?

avoid irrigation unless needed to remove an obstruction Irrigation should be avoided to prevent infection unless there is an obstruction. A closed system should be maintained using sterile technique. The smallest appropriate-sized catheter should be used.

Upon admission, the client informs the nurse of the medications he takes daily at home. When the nurse learns that the client takes amitriptyline, she anticipates the client's urine may have which discoloration?

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

A nurse is inserting an indwelling urethral catheter. Which action does the nurse take to prepare the client to cooperate during the insertion of a catheter?

close the door and curtain and explain the procedure to the client Clients who understand the procedure are more apt to relax, which facilitates the procedure and makes it more comfortable. Closing the curtain and door provides privacy. A booklet can be used to help describe the procedure but should not be the only explanation. Involving the family can be supportive but not necessarily cause the client to cooperate.

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 A condom catheter may be used in the care of male clients who lack voluntary control of urination. This is preferable to invasive catheterization (which presents an infection risk). Frequent toileting such as every 2 hours may prevent episodes of incontinence but would significantly disrupt the client's sleep quality.

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

contact the health 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 admitted to the health care facility with a diagnosis of stress incontinence. When reviewing the client's health record, what would the nurse identify as a factor contributing to the client's condition?

damage to the bladder neck 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.

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should:

deflate the balloon, insert the catheter further, and slowly attempt reinflation. If the client reports pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the client's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 0.5 to 1 in (1.25 to 2.5 cm), and slowly attempt to inflate the balloon again. Re-attempting inflation in the same location or after slight withdrawal could cause trauma to the client's urethra. It is not necessary to utilize a smaller gauge catheter.

An older woman who is a resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging?

diminished ability of the kidneys to concentrate urine Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the diminished ability of the kidneys to concentrate urine, which may result in nocturia (voiding during the night). Aging does not result in increased bladder muscle tone or increased bladder contractility. A decrease in fluid intake would not result in nocturia.

A nurse is caring for an older adult client who experiences urinary urgency. What is a possible cause of the client's condition?

diminished bladder capacity Older adults are likely to experience urinary urgency and frequency because of normal physiologic changes such as diminished bladder capacity and degenerative changes in the cerebral cortex. Impaired mobility could lead to functional incontinence. Kidney dysfunction would lead to a reduction in the volume of urine. Diuretic therapy, commonly prescribed for older adults, can increase the risk for urinary incontinence.

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?

discuss the use of protective undergarments to avoid embarrassment of 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.

A home care client has an indwelling catheter connected to a leg bag. What can the nurse recommend to help prevent development of a urinary tract infection?

empty the leg bad at regular intervals Clients with indwelling catheters are at risk for the development of a urinary tract infection. A full drainage bag may cause reflux of urine into the bladder, increasing the risk of a urinary tract infection.

The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing?

functional Functional incontinence takes place when attempting to overcome obstacles, such as transferring from the wheelchair to the bed. Other types of incontinence have different causative factors.

A 75-year-old man was admitted to the hospital for altered mental status. He had been in his usual state of good health until this morning when a nurse at the long-term care facility where he lives noticed that he was confused. Shortly after being admitted to the hospital, he became combative and had to be restrained. His bed linens have to be changed frequently because of urinary incontinence. Which nursing diagnosis best describes this client's condition?

functional incontinence Functional incontinence is the inability of a normally continent person to reach the bathroom in time to avoid the unintentional loss of urine. Stress incontinence is a state where the client loses small amounts of urine with increased pressure on the abdomen. Urge urinary incontinence is when a client experiences an involuntary loss of urine when a specific bladder volume is reached. Total urinary incontinence is when a client experiences continuous, unpredictable loss of urine.

A client at a health care facility has been diagnosed with polyuria. Which question should the nurse ask the client to determine the cause?

have you had an elevated blood sugar Polyuria means greater than normal urinary elimination. Untreated diabetes insipidus and hyperglycemia can greatly increase urine output. Ingestion of diuretics, caffeine, and alcohol also results in polyuria. Kidney disease is associated with a lack of urine output.

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 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 have the nursing diagnosis 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 Losing urine when a toilet is not readily available, urinating more than eight times in a 24 hour period, and experiencing accidental loss of urine with urgency reflect urge urinary incontinence. Other answers do not reflect assessment data associated with urge urinary incontinence.

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:

reflex incontinence The client is describing reflex 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.

A nurse is performing a client's intermittent closed catheter irrigation and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's best response to this situation?

repeat the irrigation If the tubing was not 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. There is no immediate need to contact the primary care provider or to change the catheter.

A client with a new urostomy requires teaching by the nurse. The nurse will construct the plan of care and education based upon which primary nursing diagnosis? Select all that apply.

risk for impaired skin integrity risk for infection situational low self-esteem The client with a new urostomy may be at risk for impaired skin integrity and infection if the client does not care properly for the ostomy. Therefore, the nurse will use these nursing diagnoses to plan care and education. The client may also experience a change in self-esteem due to this different way of elimination. The client will not experience types of incontinence, since the urostomy will continually drain urine.

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?

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.

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?

tell the client to take a deep breath to relax the perineal and abdominal muscles 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 working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. What is a recommended guideline for initiating this training?

the child should be able to communicate the need to void Voluntary control of the urethral sphincters occurs between 18 and 24 months of age. However, many other factors are required to achieve conscious control of bladder function, and toilet training usually begins at about 2 to 3 years of age. Toilet training should not begin until the child is able to hold urine for 2 hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet. The child's desire to gain control is also important.

A client is prescribed a diuretic for swelling of the lower extremities. What would the nurse teach the client about the effect of the medication on the client's urinary output?

the client's urinary output will be increased If the diuretic is effective, the client will have an increase in urinary output, not a decrease in urinary output. Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The odor of the urine will not have a stronger ammonia odor than usual.

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 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.

A routine urinalysis has been ordered on a client presenting to the emergency room with abdominal pain. What basic information does the nurse need to know to obtain this specimen?

the nurse will obtain a nonsterile specimen and immediately send it to the lab 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.

Which statements about suprapubic catheters is true?

they are often preferred over an indwelling urethral catheter for long-term urinary drainage Suprapubic catheters are associated with: decreased risk of contamination with organisms from fecal material; elimination of damage to the urethra; a higher rate of client satisfaction; and a lower risk of catheter-associated urinary tract infections. Suprapubic catheters are used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or gynecologic or abdominal surgery has compromised the flow of urine through the urethra. A suprapubic catheter may be preferred over indwelling urethral catheters for long-term urinary drainage in clients for whom no other alternative is possible.

A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced?

total Total incontinence takes place without a pattern or warning, and without client control, often in the presence of altered consciousness. 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. Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing.

The school nurse is caring for a student who experienced a seizure in the classroom. The student was noted to lose a large amount of urine during the seizure. Which type of incontinence does the nurse anticipate the client may have experienced?

total Total incontinence takes place without a pattern or warning, and without client control, often in the presence of altered consciousness. Other types of incontinence have different causative factors.

A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?

unless contraindicated, nurses should encourage the clients to stand to use a urinal A standing position facilitates bladder emptying and decreases the likelihood of spillage of urine. Although female urinals exist, they are more difficult to use and are not commonly used in health care facilities. Replacing urinals every 24 hours is not necessary. A urinal should not be left in place for extended periods of time, because pressure and irritation to the client's skin can result.

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Urinary incontinence is the inability for the client to control his urine. There are many different causes for urinary incontinence. Urinary tract infections are a leading cause of morbidity and health care expenditures in persons of all ages, accounting for up to 40% of infections reported by acute care hospitals. These infections can be of the upper or lower urinary system. Urinary retention is the inability to urinate. The causes of urinary retention are numerous.

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly?

use dominant hand to inflate the catheter balloon, and inject entire volume of water supplied in prefilled syringe The nurse would use the dominant hand to inflate the catheter balloon, and inject the entire volume of sterile water supplied in the prefilled syringe. The nurse would not hold the catheter 1 ft (0.3 m) from the tip. This would result in the nurse having little control over the tip of the catheter and the catheter could easily become contaminated. The nurse would not cleanse the perineal area with a gauze pad and alcohol. Iodine swabs are used to clean the perineal area prior to catheter insertion. The nurse would assist the client into the supine position, not the prone position for the procedure.

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

void and discard the urine The collection is initiated at a specific time, but the client is asked to void at that time and discard the urine from the first voiding. In most instances, a preservative is added to the collection bottle, the collected urine is kept cold through refrigeration, or it is kept on ice.