CH 37 - URINARY
The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? "Begin the collection when you first urinate in the morning." "You will need to have a catheter inserted for this collection." "Discard your first urine and begin the collection after that." "Start collecting the urine with the next time you urinate."
"Discard your first urine and begin the collection after that." Explanation: The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.
A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client? "How frequently do you urinate each day?" "Are you on any type of special diet at home?" "How often do you have a bowel movement?" "Are you on any blood pressure medications?"
"How frequently do you urinate each day?" Explanation: The client with frequent urinary tract infections may have infrequent urination, which can lead to stagnation of urine in the bladder; this potentially leads to growth of bacteria and a UTI. Taking blood pressure medication, being on a special diet, or having bowel movements do not increase the risk for urinary tract infections.
A 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 Regular toileting routine Indwelling catheterization
Regular toileting routine Explanation: The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.
Which type of incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions? overflow functional urge stress
urge Explanation: Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions.
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence? Incontinence after the age of 3 years is not normal. Daytime continence is usually not achieved by boys until age 5. Boys may take longer for daytime continence than girls. Boys may walk by 1 year and should be continent by 3 years.
Boys may take longer for daytime continence than girls. Explanation: Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.
The health care provider has requested a urine sample from a female client for urinalysis. Which method should the nurse instruct the client to use to obtain a clean-catch urine? "Begin to urinate while continuing to hold the labia apart. Allow the first urine to flow into the toilet." "Urinate directly into the specimen container, filling it half full." "Begin to urinate while continuing to hold the labia apart. Catch all urine in the container." "Catch your first urine of the day directly into the specimen container."
"Begin to urinate while continuing to hold the labia apart. Allow the first urine to flow into the toilet." Explanation: After cleansing, the client should begin to urinate while continuing to hold the labia apart. Allowing the first urine to flow into the toilet will wash microorganisms and cellular debris out of the meatus. The specimen can then be collected. The client will not collect all of the urine. The specimen is not required to be from the first urine of the day.
The nurse is caring for an older adult client suspected of having a urinary tract infection. The nurse should assess for what finding specifically associated with the development of this condition in the older adult? Dysuria Nausea Acute confusion High fever
Acute confusion Explanation: 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 will become acutely confused.
During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client? "Are you taking levodopa?" "Are you taking a diuretic?" "Are you taking any B-complex vitamins?" "Are you taking phenazopyridine?"
Are you taking any B-complex vitamins?" Explanation: Certain drugs can cause the urine to change color. Vitamin B-complexes can turn the urine green. Diuretics may cause the urine to turn pale yellow. Phenazopyridine may cause the urine to turn orange or orange-red, whereas levodopa may cause the urine to turn brown or black.
The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take? Inform the client that the health care provider will be contacted. Continue to place the indwelling catheter because it has been prescribed. Gather appropriate supplies to teach the client to perform straight catheterization. Ask the client why he or she does not want a catheter.
Ask the client why he or she does not want a catheter. Explanation: The nurse should inquire, using open-ended questioning, why the client does not want a catheter. This may allow the nurse to provide needed education. Reporting to the health care provider may be necessary but not without all of the facts about the situation. The nurse should not implement straight catheterization without a health care provider's prescription. It is unethical and inappropriate to continue to place the catheter without the client's consent.
A male client who has had outpatient surgery is unable to void while lying supine. Which intervention would be most effective in assisting the client to urinate? Ask the spouse to assist with the urinal. Assist the client to a standing position. Run water in a nearby sink. Tell the client he has to void to be discharged.
Assist the client to a standing position. Explanation: Helping clients assume their usual voiding positions may be all that is necessary to resolve an inability to void. If male clients cannot void lying down, the nurse will encourage them to void while standing at the bedside, unless this is contraindicated. While running water often helps relax clients so voiding can occur, it is not addressing the clients true need. Telling the client that he needs to void prior to discharge is putting stress on performing the activity, which is counterproductive. Asking the spouse to assist with holding the urinal may also make the client uncomfortable.
Which is true regarding the normal urination? Urinary output does not vary all that much between adults and children. In adults, the average amount of urine per void is 500 mL. 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.
Catheterized clients should drain a minimum of 30 mL of urine per hour. Explanation: Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses Chapter 37: Urinary Elimination - Page 1356.
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.
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 client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? Instruct on proper wiping technique Contact the health care provider Encourage fluids Monitor vital signs
Contact the health care provider Explanation: 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 nurse assessing an older adult client finds that the client has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause? Decreased bladder contractility Diminished ability to concentrate urine Decreased bladder muscle tone Neurologic weakness
Decreased bladder contractility Explanation: The nurse would suspect the client has decreased bladder contractility, which leads to the client having issues with urinary retention. Diminished ability to concentrate urine would be an issue with the kidney, not the urinary tract.
A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client? Urinary Incontinence related to urinary tract infection Impaired Skin Integrity related to urinary bladder infection and dehydration Impaired Skin Integrity related to functional incontinence Risk for Urinary Tract Infection related to dehydration
Impaired Skin Integrity related to urinary bladder infection and dehydration Explanation: Impaired Skin Integrity related to urinary bladder infection and dehydration would be the appropriate nursing diagnosis. The nursing concern is his excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary Tract Infection is not a nursing diagnosis, rather a medical diagnosis. The impaired skin integrity is not related to functional incontinence. Urinary Incontinence is not a nursing diagnosis, rather a medical diagnosis.
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? Have the client rest for 15 minutes before the assessment. Position the client in a supine position. Assess the client's need for analgesia. Administer a diuretic, as ordered.
Position the client in a supine position. Explanation: Portable bladder scanner results are most accurate when the client is in the supine position during the scanning. The procedure is painless, so there is no specific need to administer analgesia. Diuretics are not given in anticipation of the procedure and it is unnecessary to rest prior to scanning.
The 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.
Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into toilet or bedpan. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.
Which urinary care teaching will the nurse provide to a young adult female client? Wipe from the back to the front. Refrain from douching unless ordered by a health care provider. If you do not feel like voiding, still strain to make sure the bladder is empty. Drink water more frequently in the morning and evening to facilitate hydration.
Refrain from douching unless ordered by a health care provider. Explanation: 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.
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 had urinary catheters in place repeatedly during previous admissions. The client has a history of benign prostatic hyperplasia (BPH; prostate enlargement). The client is acutely confused and has been diagnosed with delirium.
The client is acutely confused and has been diagnosed with delirium. Explanation: A client who is acutely confused is likely unable to manipulate a urinal effectively. Kidney stones, BPH, and previous catheterizations do not preclude the use of a urinal.
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? Magnesium - 2.5 mEq/L (2.5 mmol/L) Blood urea nitrogen (BUN) - 7 mg/dL (19.6 mmol/L) Urine culture sensitivity - 100,000/mL Hemoglobin - 16 g/dL
Urine culture sensitivity - 100,000/mL Explanation: 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 is preparing to measure a client's urine output. Which interventions would be of highest priority? Measuring the urine container at eye level Wearing gloves when handling the urine Using an appropriate measuring container Noting the color and clarity of the urine
Wearing gloves when handling the urine Explanation: 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.
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? reddish-brown, clear clear, light yellow aromatic, green dark brown, cloudy
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? balanced fluids renal failure hypovolemia dehydration
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 renal failure.
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 retention catheter indwelling urethral catheter Foley catheter
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.
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: urge incontinence. reflex incontinence. stress incontinence. functional incontinence.
reflex incontinence. Explanation: 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 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? stress urge total reflect
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 nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? Asking the client when he or she had last urinated Determining any pain when palpating the lower abdomen Obtaining the bladder scanner to check the urine volume Palpating the bladder above the symphysis pubis
Asking the client when he or she had last urinated Explanation: In assessing the bladder, the nurse would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.
The UAP reports that a client on furosemide has voided 4000 mL in a 24-hour period. What is the appropriate nursing action? Document the finding as normal. Increase IV fluids. Administer an additional dose of furosemide. Contact the health care provider to decrease furosemide.
Contact the health care provider to decrease furosemide. Explanation: Voiding over 3000 mL/day is considered abnormal. The client may benefit from a reduction in the amount of furosemide that is prescribed. Therefore, it is appropriate to contact the health care provider to decrease furosemide. Documenting the finding as normal, increasing IV fluids, and administering an additional dose of furosemide are not appropriate nursing actions.
A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. -Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. -Wear underwear with a cotton crotch. -Avoid clothing that is tight and restrictive on the lower half of the body. -Dry the perineal area after urination or defecation from the back to the front. -Take baths instead of showers.
Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body. Client education can help prevent UTI recurrence. Teaching the client about measures that promote health and decrease the severity and incidence of UTIs is a major nursing responsibility. The nurse should instruct the client to drink eight to ten 8-oz glasses (1,920 to 2,400 mL) of water daily, drink two 8-oz glasses (480 mL) of water before and after sexual intercourse, void immediately after sexual intercourse, wear underwear with a cotton crotch, and avoid clothing that is tight and restrictive on the lower half of the body. Instruction should include drying the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum, as well as taking showers instead of baths.
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? Have the client drink 8 ounces of water every 15 minutes for 1 hour. Place the client on either side and rescan. Ensure proper positioning of the scanner head and rescan. Wipe off some of the ultrasound gel and rescan.
Ensure proper positioning of the scanner head and rescan. Explanation: 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.
What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? The client can apply it himself with minimal supervision. It can be left in place for a long period of time. A sterile urine specimen can be obtained from the drainage bag tubing. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.
It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. Explanation: The external condom catheter is not in the bladder. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters which are placed in the bladder. Because it is not sterile, a sterile urine specimen cannot be obtained. Often, the client does not place the external condom catheter by himself. The catheter is changed every day and the skin of the penis is assessed.
A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? loss of small amount of urine when intra-abdominal pressure rises loss of urine control because a toilet is not accessible loss of urine without any identifiable pattern or warning need to void is perceived frequently, with short-lived ability to sustain control of flow
loss of urine without any identifiable pattern or warning Explanation: The nurse could describe the client's condition as the loss of urine without any identifiable pattern or warning. Stress incontinence can be described as loss of a small amount of urine when intra-abdominal pressure rises. Urge incontinence can be described as the need to void being perceived frequently with a short-lived ability to sustain control of flow. Functional urinary incontinence can be described as the loss of control over urination because a toilet is not accessible.
The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? "I will place a bath blanket over the client to provide privacy." "The client will be placed in a reclining position with knees bent." "I will use clean gloves to handle the catheter and other equipment." "Washing hands before and after the procedure is important."
"I will use clean gloves to handle the catheter and other equipment." Explanation: Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse.
A 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? "What medications are you taking?" "You might have a neurologic condition." "You require greater privacy to void." "Stress causes the muscles to become tense."
"Stress causes the muscles to become tense." Explanation: A person's muscles may become so tense that relaxation of the perineal muscles does not occur, and voiding is inhibited.
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. Perform, or allow client to perform, perineal hygiene at least once daily. Contact the health care provider to ask for an order for catheter discontinuation. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). Ensure that the drainage bag is above the level of the bladder at all times. Discontinue to catheter and report this to the healthcare provider.
Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily. Explanation: The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.
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 from incontinence. Inform the client that this is not normal and make a referral to a urologist. Encourage the client to confide in family members and tell them about the accidents. Tell the client that this happens to all people when they get older.
Discuss the use of protective undergarments to avoid embarrassment from incontinence. Explanation: 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.
The nursing assistant reports that a client on furosemide has voided 2000 mL in a 24-hour period. What is the appropriate nursing action? Administer additional as needed (prn) dose of furosemide. Document the finding as normal. Increase IV fluids to compensate. Contact the health care provider to decrease furosemide.
Document the finding as normal. Explanation: Voiding 500-3000 mL/day is considered normal. The nurse should simply document the finding. The other actions are not necessary.
The nurse is caring for a client with urinary incontinence who has a prescription for a postvoid residual (PVR) collection. A catheter is inserted, and 45 mL of amber urine is returned via PVR. Which appropriate action would the nurse take with this data collection? Wait 30 minutes and recatheterize the client. Document the finding. Encourage the client to drink more fluids. Perform a bladder scan.
Document the finding. Explanation: A PVR of less than 50 mL indicates the bladder is adequately emptying, so the nurse should document the findings. Since this is normal there is no need to encourage more fluids, recatheterize the client, or perform a bladder scan.
A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? Monitoring the characteristics of the urinary output Calculating the flow rate of urinary output Palpating the client's bladder region Assessing PVR using a bladder scanner
The medication will be used to reduce overactivity of muscles involved in voiding, thereby lessening incontinence. Explanation: Oxybutynin (an antispasmodic) may be used to treat urinary urgency and frequency caused by overactive detrusor muscle activity.
During a visit to the pediatrician's office, a parent inquires about toilet training the 2-year-old child. Which toilet training readiness factor should the nurse include in teaching the parent about toilet training?
When your child can recognize bladder fullness. Explanation: Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for 2 hours, recognizes the feeling of bladder fullness, communicates the need to void, and controls urination until seated on the toilet.
The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify? urinary tract infection (UTI) urinary incontinence urinary suppression urinary retention
urinary retention Explanation: 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.
Which symptom will have a great impact on the extracellular fluid for water conservation? Pain Burns Small laceration Fracture
Burns Explanation: The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.
A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority? Notifying the health care provider of the assessment findings Checking for blood return in the CVC Obtaining laboratory studies Placing the client as N.P.O. status
Notifying the health care provider of the assessment findings Explanation: The assessment is indicative of hospital-acquired catheter infection associated with the CVC. The medical provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Checking for blood return is not indicated and access to the CVC used for hemodialysis should not be attempted without a prescription to do so from the health care provider.
The health care provider requests an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position? Sims Supine Dorsal recumbent Semi-Fowler
Sims Explanation: The Sims, or 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 position.
The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client? A urinary tract infection results from the birth process. Catheterization is necessary for 1 week. A neurogenic bladder results from local anesthesia. The birth can cause perineal swelling.
The birth can cause perineal swelling. Explanation: 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 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. 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 soaks in the bathtub daily for perineal care.
The client drinks two glasses of water before and after sexual intercourse. Explanation: Drinking water before sexual intercourse aids in adequate urinary stream to flush any bacteria that may have entered during sex. The client should drink 10 oz of cranberry juice daily; take a shower instead of a tub bath; and continue the full course of antibiotics even if symptom-free.
During a visit to the pediatrician's office, a parent inquires about toilet training the 2-year-old child. Which toilet training readiness factor should the nurse include in teaching the parent about toilet training? When your child can recognize bladder fullness. When your child can hold the urine for 4 to 5 hours. When you child continues playing when diapers are wet. When your child expresses interest in the toilet.
When your child can recognize bladder fullness. Explanation: Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for 2 hours, recognizes the feeling of bladder fullness, communicates the need to void, and controls urination until seated on 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 infection stasis dehydration
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 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. wait for 30 seconds, help the client to relax, and attempt inflation again. deflate the balloon, withdraw the catheter, and use a smaller sized catheter. stop, deflate the balloon, withdraw the catheter 0.75 to 1.5 in (2 to 4 cm), and slowly reinflate.
deflate the balloon, insert the catheter further, and slowly attempt reinflation. Explanation: If the client reports pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the client's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 0.5 to 1 in (1.25 to 2.5 cm), and slowly attempt to inflate the balloon again. Re-attempting inflation in the same location or after slight withdrawal could cause trauma to the client's urethra. It is not necessary to utilize a smaller gauge catheter.
A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? "Don't worry, this is a normal condition for older adults." "Let's explore structuring activities and toileting breaks." "Let me refer you to a urologist who can help you." "It would be best just to get some adult diapers."
"Let's explore structuring activities and toileting breaks." Explanation: The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.
The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client? "You will have a catheter put in to collect the urine." "Void a small amount, stop, and discard it." "Void into the specimen hat in the toilet bowl." "Save all urine for the next 24 hours."
"Void a small amount, stop, and discard it." Explanation: When collecting a midstream urine specimen, the client voids a small amount, stops, and discards it; the first small amount helps to flush away organisms near the urinary meatus. The midstream urine specimen is a sterile specimen so it is not collected in the hat in the toilet bowl. The client will not need to be catheterized. It is a one-time specimen, so urine will not be collected for 24 hours.
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? clean-catch specimen random specimen 24-hour specimen intermittent specimen
24-hour specimen Explanation: A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.
During the well-child checkup for 2-year-old twins (one boy, one girl), their mother asks the nurse about preparing to toilet train the children. What information can be provided to the parent? Select all that apply. Children old enough to undress themselves will have increased abilities to toilet train. Nighttime continence will occur in some children after age 4 or 5 years. Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training. It is typically more difficult to toilet train a female child. Daytime incontinence is not a concern while toilet training
Daytime incontinence is not a concern while toilet training Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training. Children old enough to undress themselves will have increased abilities to toilet train. Beginning sometime between 2 and 3 years of age, parents should to watch for signs that a child may be ready for toilet training. These signs include staying dry for two hours at a time or dry after naps, as well as being able to walk to the bathroom and ability to undress themselves. Most children will achieve daytime urinary control by 3 to 4 years of age. Sometimes, toddlers need to experience outdoor playtime without diapers to see what happens when they experience bladder fullness, followed by urethral relaxation and bladder emptying. They begin to understand the relationship between bladder fullness and voluntary bladder emptying and are ready for toilet training. Nighttime continence may not occur until 4 or 5 years of age.
The nurse has received an order to catheterize a female client. What action should the nurse perform? Lubricate 3 to 4 in of the catheter tip before insertion. Using both hands, hold the catheter near the tip and insert slowly into the urethra. Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm). Advance the catheter until slight resistance is felt.
Once urine drains, advance the catheter another 2 to 3 inches (5 to 7.5 cm). Explanation: The nurse should lubricate 1 to 2 in (2.5 to 5 cm) of the catheter tip and, using the dominant hand, hold the catheter 2 to 3 in (5 to 7.5 cm) from the tip and insert slowly into the urethra. The nurse should then advance the catheter until there is a return of urine (approximately 2 to 3 in [5 to 7.5 cm]) and, once urine drains, advance catheter another 2 to 3 in (5 to 7.5 cm). The nurse may encounter slight resistance when advancing the catheter, but this does not necessarily indicate correct placement; further advancement of the catheter may be necessary to obtain urine flow.
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? Overflow incontinence Stress incontinence Functional incontinence Total 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.
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? Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. 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. 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. Explanation: The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.
A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? urge reflex total stress
stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.
The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate? clear, colorless light yellow, clear cloudy, foul odor strongly aromatic, dark amber
strongly aromatic, dark amber Explanation: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.
The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will: keep the labia spread after cleaning and during collection of the specimen." urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." wash my hands before collecting the clean catch urine specimen." use three wipes provided; one to clean each side of the urinary meatus, and one in the middle from front to back."
urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." Explanation: The client accurately details the steps of the procedure except the nurse needs to further instruct the client that the client needs to void a small amount of urine into the toilet and then stop urination for a short time and then void around 3 to 5 mL into the cup.
