Ch 37 Urination PrepU

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

*cloudy, foul odor

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 *renal failure

*dehydration

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?

"I make sure to limit how much I drink so that I don't have accidents."

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?

"Let's explore structuring activities and toileting breaks."

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?

"Let's review the types of fluids that your child drinks in the morning."

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?

"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 healthcare provider without taking a history, and it is impractical to simply recommend incontinence undergarments.

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"Let's review your medication history and whether you consume bladder irritants."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"Let's review your medication history and whether you consume bladder irritants." Urge incontinence can be aggravated by bladder irritants such as caffeine or alcohol, and can take place if diuretics are taking in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the healthcare provider, or to recommend incontinence undergarments.

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?

"Stress causes the muscles to become tense."

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

"Void a small amount, stop, and discard it.

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

"Void a small amount, stop, and discard it."

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

"Void a small amount, stop, and discard it." When collecting a midstream urine specimen, the client voids a small amount, stop, 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.

The nurse has provided instructions to a client having a fecal immunochemical test (FIT). The client states, "I am menstruating right now. Is it okay to still do the test?" What is the best response by the nurse?

"Wait to do the test 3 days after your finish menstruating."

The nurse is assessing a female client who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply?

"You are experiencing stress incontinence. Do you know how to do Kegel exercises?"

A woman age 76 years has informed the nurse that she has begun using over-the-counter laxatives because her friend told her it was imperative to have at least one bowel movement daily. How should the nurse best respond to this client's statement? *"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day." *"Your friend is correct in her assessment, but it would likely be better to exercise and drink more instead of using medications." *"Most older adults only have a bowel movement every 2 to 3 days, actually, so I'd encourage you to taper off your laxatives." *"That's correct, but be sure that you don't increase your laxative doses over time."

*"Actually, people's bowel patterns can vary a lot and some people don't tend to go every day."

A client with no significant medical history reports experiencing diarrhea over the past week. Which assessment question will the nurse ask? Select all that apply. *"Have you started a new medication?" *"What are your normal bowel habits?" *"Are you experiencing rectal fullness?" *"Do you use laxatives?" *"Is the stool difficult to pass?"

*"Have you started a new medication?" *"What are your normal bowel habits?" *"Do you use laxatives?"

The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching? *"A woman using an intrauterine device for contraceptive reason is at risk for developing a UTI." *"I will make sure to teach my clients with diabetes mellitus to control their glucose level to help prevent a UTI." *"Having sexual relationships does not put a woman at risk for developing a UTI." *"Due to the physiologic changes with aging, the elderly are at risk for developing a UTI."

*"Having sexual relationships does not put a woman at risk for developing a UTI."

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? *"This 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."

A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training? *"Your child will tell you when there is a sensation of bladder fullness." *"One signal of preparedness is when your child is dry for at least 2 hours." *"Your child should be at least 2 years old before you start toilet training." *"Girls typically take longer than boys to be ready for toilet training."

*"One signal of preparedness is when your child is dry for at least 2 hours."

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

*"Stress causes the muscles to become tense."

A client has been given fecal occult blood test (FOBT) testing supplies. What teaching will the nurse provide about the purpose for this test? *"This will determine what foods you are allergic to that affect digestion and elimination." *"This test gives the healthcare provider a very accurate indication about whether you may have colorectal cancer." *"This test detects heme, an iron compound in blood within the stool." * "This test will help determine whether you have an infectious process in the intestines."

*"This test detects heme, an iron compound in blood within the stool."

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client? *"Void into the specimen hat in the toilet bowl." *"Void a small amount, stop, and discard it." *"Save all urine for the next 24 hours." *"You will have a catheter put in to collect the urine."

*"Void into the specimen hat in the toilet bowl."

The nurse is providing health teaching for four clients. Which client should consider a colonoscopy screening? *33-year-old client who reports painful elimination *42-year-old client with diarrhea twice weekly *(50-year-old client with a family history of polyps *67-year-old client with constipation

*(50-year-old client with a family history of polyps

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

The nurse is talking with four members of a family. Which client within the family does the nurse identify that would benefit from discussing a colonoscopy screening with their health care provider? *18-year old who with diarrhea twice weekly *22-year old who experiences constipation *47-year old whose father had polyps *48-year old with regular bowel habits

*47-year old whose father had polyps

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide? *Collect the first urine expelled. *After the initial stream is initiated, collect the sample. *Wait until the void is almost over to collect a specimen. *Collect the entire urinary output.

*After the initial stream is initiated, collect the sample.

A nurse is caring for a client with an NG tube attached to continuous suction. The nurse observes that the tube is connected to the wall suction, but it is not draining. What is the nurse's best action? *Turn off the suction for 30 minutes and then turn it on again. *Attempt to irrigate the NG tube with water or normal saline. *Instill digestive enzymes, as ordered. *Remove the NG tube and replace it with a larger-bore tube, as ordered.

*Attempt to irrigate the NG tube with water or normal saline.

A client is preparing for a fecal occult blood test. What teaching will the nurse provide regarding vitamin C three days before testing? *Take 500 mg *Consume citrus fruits *Drink orange and grapefruit juice *Avoid more than 250 mg

*Avoid more than 250 mg

A nurse prepares to insert a nasointestinal tube to provide nutrition to a client. Which guideline is recommended for this procedure? *Administer an oral analgesia 30 to 45 minutes before attempting insertion. *Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process. *Add 16 to 18 in to the measurement obtained to ensure the tube comes to rest at the desired point. *Position the bed flat and assist the client onto his or her left side.

*Begin by measuring from the tip of the client's nose to the earlobe to the xiphoid process.

An older adult woman who is incontinent of stool following a cerebrovascular accident will have which nursing diagnosis? *Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate *Diarrhea related to tube feedings, as evidenced by hyperactive bowel sounds and urgency *Constipation related to physiologic condition involving the deficit in neurologic innervation, as evidenced by fecal incontinence *Fecal Retention related to loss of sphincter control, and diminished spinal cord innervation related to hemiparesis

*Bowel Incontinence related to loss of sphincter control, as evidenced by inability to delay the urge to defecate

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. *Boys may take longer for daytime continence than girls. *Boys may walk by 1 year and should be continent by 3 years. *Daytime continence is usually not achieved by boys until age 5.

*Boys may take longer for daytime continence than girls.

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.

A nurse is testing a client's stool specimen for occult blood. Which are responsibilities of the nurse for this testing? Select all that apply. *Ordering the test *Collecting the specimen *Handling the specimen *Transporting the specimen *Teaching the client about the test *Planning medical treatment based on test results

*Collecting the specimen *Handling the specimen *Teaching the client about the test

Upon removing the lid of a tray for a client who is lactose intolerant, the nurse discovers which food is not permitted in this client's diet? *Custard *Chicken *Lettuce salad *Baked potato

*Custard

Which symptom is a known side effect of antibiotics? *Diarrhea *Constipation *Fecal impaction *Abdominal bloating

*Diarrhea

Which statement best explains why digital removal of stool is considered a last resort after other methods of bowel evacuation have been unsuccessful? *Digital removal of stool may cause parasympathetic stimulation. *Nurses find the procedure distasteful and difficult to perform. *Most clients will not consent to have digital removal of stool. *It often causes rebound diarrhea and electrolyte loss.

*Digital removal of stool may cause parasympathetic stimulation.

The nurse is preparing to auscultate the bowel sounds of a client with a nasogastric tube in place set to low intermittent suction. How shall the nurse approach the assessment of bowel sounds and manage the nasogastric tube? *Disconnect the nasogastric tube from suction during the assessment of bowel sounds. *Apply continuous suction to the nasogastric tube during assessment of bowel sounds. *Allow the low intermittent suction to continue during the assessment of bowel sounds. *Disconnect the nasogastric tube from the suction for 1 hour prior to the assessment of bowel sounds.

*Disconnect the nasogastric tube from suction during the assessment of bowel sounds.

A registered nurse is overseeing the care of numerous clients on an acute medicine unit. Which task should the nurse delegate to unlicensed assistive personnel (UAP)? *Emptying a client's ileostomy appliance *Assessing a client's GI system *Inserting a client's NG tube *Irrigating a client's NG tube

*Emptying a client's ileostomy appliance

The nurse is caring for a client who is scheduled for an esophagogastroduodenoscopy (EGD). What action would the nurse take to prepare the client for this procedure? *Ensure that the client ingests a gallon of bowel cleanser, such as polyethylene glycol electrolyte solution, in a short period of time. *Inform client that a chalky-tasting barium contrast mixture will be given to drink before the test. *Provide a light meal before the test and administer two Fleet enemas. *Ensure that the client fasts 6 to 12 hours before the test as per policy.

*Ensure that the client fasts 6 to 12 hours before the test as per policy.

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? *Visible waves of abdominal peristalsis *Hyperactive bowel sounds *Increased anal area pigmentation *Dry, hard stool

*Hyperactive bowel sounds

A nurse is teaching a student nurse how to manage unexpected events during the removal of a nasogastric tube. Which action should the nurse recommend? *If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider. *Replace the NG tube if the client experiences nausea within 6 hours of removal. *If the client experiences pain during removal, apply petroleum jelly to the skin near the exit site. *If epistaxis occurs with removal of the NG tube, ensure that the client is in a supine position with an ice pack applied.

*If within 2 hours after NG tube removal, the client's abdomen is showing signs of distention, notify the health care provider.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence? *It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters. *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.

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.

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? *Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. *Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics. *Ask the client to bear down until the catheter is expelled. *Remove the catheter from the vagina and attempt to insert it into the bladder.

*Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

A nurse is giving an enema to a client who doubles over in pain with severe cramping. What intervention would be appropriate in this situation? *Remove the tubing and discontinue the procedure. *Lower the solution container and check the temperature and flow rate. *Place the client on a bedpan in the supine position while receiving the enema. *Reposition the rectal tube and check for any fecal content.

*Lower the solution container and check the temperature and flow rate.

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? *Checking for blood return in the CVC *Placing the client as N.P.O. status *Notifying the health care provider of the assessment findings *Obtaining laboratory studies

*Notifying the health care provider of the assessment findings

A nurse is performing an abdominal assessment of a client before administering a large-volume cleansing enema. Which assessment technique would be performed last? *Palpation *Percussion *Auscultation *Inspection

*Palpation

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? *Moist perineal skin *Reddened perineal skin *Presence of smegma *Absence of discharge

*Reddened perineal skin

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? *Wait 1 hour and repeat the irrigation. *Notify the primary care provider promptly. *Repeat the irrigation. *Prepare to change the catheter.

*Repeat the irrigation.

The nurse is inserting a rectal tube to administer a large-volume enema. Which nursing action is performed correctly in this procedure? *Position the client on his back and drape properly. *Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult. *Introduce solution quickly over a period of 3 to 5 minutes. *Encourage the client to hold the solution for at least 20 minutes.

*Slowly and gently insert the enema tube 3 to 4 in (7.5 to 10 cm) for an adult.

The student nurse is administering a large-volume enema to a client. The client reports abdominal cramping. What should the student nurse do first? *Increase the flow of the enema for approximately 30 seconds then decrease it to the prior flow rate. *Stop the administration of the enema and notify the physician. *Stop the administration of the enema momentarily. *Increase the flow of the enema until all of the solution has been administered.

*Stop the administration of the enema momentarily.

While administering a cleansing enema, the client displays lightheadedness, nausea, and has clammy skin. The nurse would implement which priority action? *Stop the procedure and reposition the client. * Slow the infusion rate, have the client take deep breaths, then resume the enema. *Slow the infusion rate, withdraw the tubing slightly, then resume the enema. *Stop the procedure, monitor heart rate and blood pressure.

*Stop the procedure, monitor heart rate and blood pressure.

The nurse is slowly advancing a nasogastric (NG) tube when the client begins to gasp and is unable to vocalize. Which scenario has likely occurred? *The NG tube is in the client's airway. *The NG tube is curled in the back of the client's throat. *The client is experiencing a vasovagal reaction. *The client is forcefully resisting the procedure.

*The NG tube is in the client's airway.

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. *The diameter of the catheter is too large. *The nurse failed to deflate the retention balloon after pretesting it for integrity. * The client has an occult abscess in the urethra.

*The client has an enlarged prostate.

The newly hired graduate nurse is preparing to administer a cleansing enema. The nurse educator will intervene if which action is taken by the graduate nurse? *The graduate advises the client that the enema should not be expelled immediately. *The graduate uses a room temperature solution. *The graduate places the client in Fowler's position. *The graduate takes this opportunity to teach about the function of the intestinal tract.

*The graduate places the client in Fowler's position.

When caring for a client with a new colostomy, which assessment finding would be considered abnormal and would need to be reported to the physician? *The stoma is pink. *The stoma has a small amount of bleeding. *The stoma is prolapsed. *The stoma is on the abdominal surface.

*The stoma is prolapsed.

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed? *The student had the client flex the knees when performing the assessment. *The student sequenced from auscultation to inspection, and percussion to palpation. *The student placed the client in supine position with the abdomen exposed. *The student instructed the client to urinate before beginning the focused assessment.

*The student sequenced from auscultation to inspection, and percussion to palpation.

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? *Stress incontinence *Functional incontinence *Total incontinence *Overflow incontinence

*Total incontinence

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? *Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. *Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. *Perform hand hygiene between cleansing the woman's labia and inserting the catheter. *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.

When caring for a client with difficulty defecating, which appropriate nursing interventions would the nurse implement? Select all that apply. *Elevate the bed to 15 degrees when using the bedpan. *Use moist heat when cleaning the perineal area. *Encourage daily consumption of 2,000 to 3,000 mL of water. *Encourage decreasing the amount of fiber in diet. *Encourage the client to exercise once a week.

*Use moist heat when cleaning the perineal area. *Encourage daily consumption of 2,000 to 3,000 mL of water.

The nurse is teaching a client with a new ostomy about skin care to preserve tissue integrity at the stomal site. Which teaching will the nurse provide regarding cleansing the stoma? *Use water only. *Use alcohol-based sanitizer. *Use water and mild soap. *Use mineral oil.

*Use water and mild soap.

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.

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity? *Wash it with a mild cleanser and water. *Avoid using commercial skin preparations. *Clean it with a dry, cotton bandage. *Avoid applying a barrier substance.

*Wash it with a mild cleanser and water.

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

*Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

The nurse is presenting a lecture on ostomy bowel elimination at a community clinic. When questioned by the clients, which food would the nurse suggest as natural intestinal deodorizers? *Asparagus and turnip *Fish and dried lentils *Yogurt and buttermilk *Onions and garlic

*Yogurt and buttermilk

Which client is most likely to require interventions in order to maintain regular bowel patterns? *a client whose neuropathic pain requires multiple doses of opioids each day *a client with hypertension who takes a diuretic and adrenergic blocker each morning *a client who has a history of atrial fibrillation requiring daily anticoagulants *a woman 59 years of age who has recently begun hormone replacement therapy

*a client whose neuropathic pain requires multiple doses of opioids each day

A nurse is caring for a client with constipation. The incidence of constipation tends to be high among clients who follow which diet? *a diet lacking in fruits and vegetables *a diet lacking in glucose and water *a diet consisting of whole grains, seeds, and nuts *a diet lacking in meat and poultry products

*a diet lacking in fruits and vegetables `

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

*a flexible sheath that is rolled around the penis

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

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? *dehydration *infection *stasis *blood

*blood

A student nurse studying human anatomy knows that a structure of the large intestine is the: *duodenum * jejunum *ileum *cecum

*cecum

A client scheduled for a colonoscopy is scheduled to receive a hypertonic enema prior to the procedure. A hypertonic enema is classified as which type of enema? *cleansing enema *retention enema *carminative enema *return-flow enema

*cleansing enema

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 *dark brown, cloudy *aromatic, green

*dark brown, cloudy

A 57-year-old man is suffering from polyuria. What can cause polyuria? *diabetes insipidus *renal disease *urinary tract infection *renal calculi

*diabetes insipidus

The nurse is scheduling tests for a client who is experiencing bowel alterations. What is the most logical sequence of tests to ensure an accurate diagnosis? * barium studies, endoscopic examination, fecal occult, blood test *fecal occult blood test, barium studies, endoscopic examination *barium studies, fecal occult blood test, endoscopic examination *endoscopic examination, barium studies, fecal occult blood test

*fecal occult blood test, barium studies, endoscopic examination

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? *before bedtime *afternoon *evening *first thing in the morning

*first thing in the morning

A 60-year-old client is experiencing pain that can be attributed to distention of the veins in her rectum. What health problem is this client most likely experiencing? *hemorrhoids *diarrhea *paralytic ileus *constipation

*hemorrhoids

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. 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

When caring for a client with fecal incontinence, the nurse knows that fecal incontinence is the result of: *nature and amount of food eaten by the client. *drinking and smoking habits of the client. *physiologic or lifestyle changes in the client. *social and emotional setting of the client.

*physiologic or lifestyle changes in the client.

The nurse is caring for a client on bed rest who has constipation. How will the nurse document this finding? *primary constipation *secondary constipation *iatrogenic constipation *pseudoconstipation

*primary constipation

The nurse is caring for an older adult client with diarrhea. Which assessment finding requires immediate nursing intervention? *blood pressure 130/80 mm Hg *temperature 99.9°F (37.9°C) *skin turgor response 5 seconds *heart rate 90 beats/min

*skin turgor response 5 seconds

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 *total *reflex *stress

*stress

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 retention *urinary incontinence *urinary suppression

*urinary retention

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

A clean-catch specimen is collected in mid-stream. It is not reasonable, nor necessary, to collect the entire urinary output. It is not correct to collect the first urine expelled or to wait until the void is almost over.

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

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

d (Polyuria means greater than normal urinary elimination. It may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects -e.g., coffee, tea-, or taking certain medications actually can increase urination. Oliguria is inadequate elimination of urine. Anuria means the absence of urine. Dysuria is difficult or uncomfortable voiding.)

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

a (The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.)

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. Which of the following describes a urinary diversion? a) One or both of the ureters are surgically implanted elsewhere b) Hygiene measures used to keep meatus and adjacent area of the catheter clean. c) Use of a catheter to collect urine in a sterile environment d) Inability to control either urinary or bowel elimination

d (Stress incontinence can be described as loss of a small amount of urine when intra-abdominal pressure rises; whereas, urge incontinence can be described as the need to void is perceived frequently with a short-lived ability to sustain control of flow. Functional urinary incontinence can be described as the loss of control over urination because a toilet is not accessible.)

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

c (Neurologic injury after a stroke or spinal cord injury can disrupt normal patterns of urinary elimination. This condition is called neurogenic bladder. A cystocele is a herniation of the urinary bladder. Enuresis is the clinical term for bedwetting. An overactive bladder is the term used when a person has increased urinary urge, increased urinary frequency, or both.)

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

a (Urine may be dark amber or orange-brown if it is very concentrated secondary to a decreased fluid intake. Urine is lighter than normal if it is diluted. Foods or drugs can also alter the color of urine. Tea-colored or very dark urine is a sign of dehydration.)

A client has been NPO after midnight for surgery. It is 11 AM and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color? a) Dark amber b) Pale yellow c) Tea colored d) Colorless

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

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

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

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

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

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

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

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

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

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? a) Intermittent urethral catheter b) Indwelling urethral catheter c) Foley catheter d) Retention catheter

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

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

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

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? a) Urge incontinence b) Reflex incontinence c) Stress incontinence d) Functional incontinence

d (When providing continuous irrigation, the nurse must purge the air from the tubing to ensure that no air enters the system. The nurse should hang the sterile irrigating solution from an IV pole, rather than place it on the bed, to allow it to flow freely. The nurse empties the balloon with a syringe and also cleans the urinary meatus when removing the catheter and not when irrigating the catheter.)

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

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

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

b (A condom catheter is a flexible sheath that is rolled around the penis. A urinary bag -U-bag- is a bag attached by adhesive backing to the skin surrounding the genitals. A straight catheter is a urine drainage tube inserted but not left in place; a retention catheter is a urine drainage tube that is left in place over a period of time.)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

b

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

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

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

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

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

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

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

a (When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens. A specimen from the collecting receptacle -drainage bag- may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen.)

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

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

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

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

A woman informs the nurse that when she is experiencing stress it is difficult to void, and wonders why this happens. What is the nurse's best explanation? a) "You might have a neurologic condition." b) "What medications are you taking?" c) "You require greater privacy to void." d) "Stress causes the muscles to become tense."

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

After the initial stream is initiated, collect the sample. A clean-catch specimen is collected in mid-stream. It is not reasonable, nor necessary, to collect the entire urinary output. It is not correct to collect the first urine expelled or to wait until the void is almost over.

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

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

c (The client is describing overflow incontinence, which occurs when the bladder muscle distends and urine is forced out. Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contraction. Stress incontinence is caused by weakening of the pelvic floor muscle or urethral hypermobility. Functional incontinence occurs when a physical or psychological impairment impedes continence despite a competent urinary system.)

An older adult woman tells the nurse that she has trouble controlling her urine. She states, "The urine starts dripping even before I feel like I have to go." The nurse interprets this as which of the following? a) Stress incontinence b) Urge incontinence c) Overflow incontinence d) Functional incontinence

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

Ans C: Nocturia and urinary retention are common in older adults.

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 a) Condom catheter b) Indwelling catheter c) Intermittent catheterization at bedtime d) Adult incontinence briefs

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

A nurse who is providing continence training to a client plans a trial schedule for voiding that correlates with the time when the client is usually incontinent. Which of the following is the best reason for the nurse's plan of action? a) It shows respect for the client's schedule. b) It ensures adequate urine volume. c) It reveals the client's type of incontinence. d) It prevents self‐defeating consequences.

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

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A. Suprapubic catheter B. Indwelling urethral catheter C. Intermittent urethral catheter D. Straight catheter

Ans: A Feedback: A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra.

The physician has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? a. The male urethra is more vulnerable to injury during insertion. b. In the hospital, a clean technique is used for catheter insertion. c. The catheter is inserted 2″ to 3″ into the meatus. d. Since it uses a closed system, the risk for urinary tract infection is absent.

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

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

Ans: A Feedback: Diuretics result in moderate to severe increases in the production of dilute urine. Concentration will decrease, not increase, and there is no accompanying risk of urinary tract infections. For some clients, this sudden increase in urine output may precipitate transient incontinence, but this remains an abnormal finding.

A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? a. Decreased and highly concentrated b. Decreased and highly dilute c. Increased and concentrated d. Increased and dilute

Ans: A Feedback: Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.

A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding? A. Assist him to a standing position. B. Tell him he has to void to be discharged. C. Pour cold water over his genitalia. D. Ask his wife to assist with the urinal.

Ans: A Feedback: 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, encourage them to void while standing at the bedside unless this is contraindicated.

A nurse is assessing the urine output of a client with Parkinson's disease who is on levodopa. Which of the following is a common finding for a client on this medication? A. The urine may be brown or black. B. The urine may be blood-tinged. C. The urine may be green or blue-green. D. The urine may be orange or orange-red.

Ans: A Feedback: Levodopa (l-dopA. , an antiparkinson drug, and injectable iron compounds can lead to brown or black urine. Anticoagulants may cause hematuria (blood in the urinE. , leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine (Pyridium), a urinary tract analgesic, can cause orange or orange-red urine.

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? A. Diminished kidney ability to concentrate urine B. Increased bladder muscle tone causing urinary frequency C. Increased bladder contractility causing urinary stasis D. Decreased intake of fluids during daytime hours

Ans: A Feedback: Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the diminished ability to concentrate urine that 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 using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which of the following positions would the nurse place the client? A. Supine B. Sims' C. High Fowler's D. Dorsal recumbent

Ans: A Feedback: Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Results are most accurate when the client is in the supine position during the scanning.

A nurse is caring for a patient who is taking phenazopyridine (Pyridium, a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish-red today; is there something wrong with me?" What would be the nurse's best response? a. "This is a normal finding when taking phenazopyridine." b. "This may be a sign of blood in the urine." c. "This may be the result of an injury to your bladder." d. "This is a sign that you are allergic to the medication and must stop it."

Ans: A Feedback: Pyridium is noted for turning the urine orange-red; the patient needs to be aware of this.

A nurse is caring for a male patient who had a condom catheter applied following hip surgery. What action would be a priority when caring for this patient? a. Preventing the tubing from kinking to maintain free urinary drainage b. Not removing the catheter for any reason c. Fastening the condom tightly to prevent the possibility of leakage d. Maintaining bedrest at all times to prevent the catheter from slipping off

Ans: A Feedback: The catheter should be allowed to drain freely through tubing that is not kinked. It also should be removed daily to prevent skin excoriation and should not be fastened too tightly or restriction of blood vessels in the area is likely. Confining a patient to bedrest increases the risk for other hazards related to immobility

A nurse 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? A. Void and discard the urine. B. Begin the collection at a specific time. C. Add the first voiding to the specimen. D. Keep the urine warm during collection.

Ans: A Feedback: 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, or the collected urine is kept cold through refrigeration or putting it on ice.

Which of the following describes the term micturition? A. Emptying the bladder B. Catheterizing the bladder C. Collecting a urine specimen D. Experiencing total incontinence

Ans: A Feedback: The process of emptying the bladder is known as urination, micturition, or voiding.

A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? A. Urinary incontinence B. Urinary incompetence C. Normal micturition D. Uncontrolled voiding

Ans: A Feedback: The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence.

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

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

An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses? A. Social Isolation B. Impaired Adjustment C. Defensive Coping D. Impaired Memory

Ans: A Feedback: Urinary incontinence is a special problem for older adults who may have decreasing control over micturition, or find it more difficult to reach the toilet in time. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person's self-concept, causing him or her to feel like a social outcast.

After surgery, a postoperative client has not voided for eight hours. Where would the nurse assess the bladder for distention? A. Between the symphysis pubis and the umbilicus B. Over the costovertebral region of the flank C. In the left lower quadrant of the abdomen D. Between ribs 11 and 12 and the umbilicus

Ans: A Feedback: When the bladder is distended with urine, it rises above the symphysis pubis and may reach to just below the umbilicus. The other choices are anatomically incorrect for assessing a distended bladder.

The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The presence of which of the following will support the potential diagnosis? a) Pus b) Casts c) Calculi d) Protein

Ans: A Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI.

A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? a) Stress incontinence b) Functional incontinence c) Reflex incontinence d) Urge incontinence

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

A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. a. A 78-year-old male patient diagnosed with an enlarged prostate b. An 83-year-old female patient who is on bedrest c. A 75-year-old female patient who is diagnosed with vaginal prolapse d. An 89-year-old male patient who has dementia e. A 73-year-old female patient who is taking antihistamines to treat allergies f. A 90-year-old male patient who has difficulty walking to the bathroom

Ans: A,C,E Feedback: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.

A nurse is caring for a 56-year-old male patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply a. Measure the patient's fluid intake and output. b. Keep the skin around the stoma moist. c. Empty the appliance frequently. d. Report any mucous in the urine to the primary care provider. e. Encourage the patient to look away when changing the appliance. f. Monitor the return of intestinal function and peristalsis.

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

A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? a) Foley catheter b) Intermittent urethral catheter c) Retention catheter d) Indwelling urethral catheter

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

The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnoses is the most appropriate for this client? A. Risk for activity intolerance B. Risk for impaired skin integrity C. Risk for infection D. Risk for falls

Ans: B Feedback: A client who is incontinent, utilizes adult diapers, and only changes them daily is at Risk for Impaired Skin Integrity in the genital and perineal area.

A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client? A. Public embarrassment B. Skin breakdown and UTI C. Inability to control urine D. Odor and leakage

Ans: B Feedback: Clients frequently turn to absorbent products for protection when they are incontinent of urine and if they have not had this condition properly diagnosed and treated. When used improperly, such products may cause skin breakdown and place the client at risk for a UTI.

A client is admitted to the health care facility with complaints of pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as which of the following? A. Polyuria B. Dysuria C. Nocturia D. Hematuria

Ans: B Feedback: Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a burning sensation during urination. Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent increase in fluid intake. Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood in the urine.

After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? a. Pouring warm water over the patient's fingers. b. Having the patient ignore the urge to void until her bladder is full. c. Using a warm bedpan when the patient feels the urge to void. d. Stroking the patient's leg or thigh.

Ans: B Feedback: Ignoring the urge to void makes urination even more difficult and should be avoided. The other activities are all recommended nursing activities to promote voiding.

A nurse forms the following nursing diagnosis for a patient: Impaired Urinary Elimination related to maturational enuresis. Based on this diagnosis, for which patient is the nurse caring? a. An adult older than 65 years of age who is incontinent b. A child older than 4 years of age who has involuntary urination c. A 12-month-old child who has involuntary urination d. A patient with neurologic damage resulting in bladder dysfunction

Ans: B Feedback: Maturational enuresis is involuntary urination after an age when continence should be present. A 12-month-old child is not expected to be continent, and incontinence and neurologic damage are not maturational problems

What is the micturition reflex? A. The process of filtration beginning with the glomerulus B. The act of bladder contraction and perceived need to void C. The reabsorption of the substances the body wants to retain D. The secretion of electrolytes that are harmful to the body

Ans: B Feedback: Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition.

A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A. A clean catheter and rubber gloves B. A sterile catheterization kit or tray C. Solutions to sterilize the urethra D. Solutions to sterilize the vagina

Ans: B Feedback: The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The equipment used for catheterization is usually prepackaged in a sterile disposable kit or tray.

A client with a urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following A. "I should take frequent bubble baths." B. "I need to void after sexual intercourse." C. "I should wipe from back to front after going to the bathroom." D. "I need to wear pants that are snug fitting."

Ans: B Feedback: The client's statement about voiding after sexual intercourse to prevent urinary tract infection is accurate. Taking frequent bubble baths, wiping the perineum from back to front, and wearing snug fitting pants increases the risk of urinary tract infection. The client should avoid taking frequent bubble baths, using harsh soaps, and wearing tight-fitting pants because they can irritate the urethra. The client also should always wipe from front to back after urinary or fecal elimination.

A nurse caring for a patient's hemodialysis access documents the following: "5/10/15 0930 Arteriovenous fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill1340 U N I T V I I Promoting Healthy Physiologic Responses noted." Which documented finding would the nurse report to the primary care provider? a. Positive bruit noted. b. Area is warm to touch and edematous. c. Patient denies pain and tenderness. d. Positive thrill noted.

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

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? A. Urinary incontinence B. Urinary retention C. Involuntary voiding D. Urinary frequency

Ans: B Feedback: 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. Incontinence is involuntary loss of urine from the bladder. Retention is an accumulation of urine in the bladder. Frequency is voiding more often than usual.

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

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

The nursing student who is learning skills during campus lab identifies which of the following statements about bedpans to be true? a) A regular bedpan is generally more comfortable for clients than a fracture bedpan. b) The rounded shelf of a regular bedpan should be placed under the client's buttocks. c) A fracture pan is preferred for urination and a regular bedpan is preferred for defecation. d) A fracture bedpan should used only for clients who have fractures of the femur or lower spine.

Ans: B The only true statement is that the rounded shelf of the regular bedpan should be placed under the client's buttocks. Very thin and older adult clients may prefer the fracture bedpan. Both types of bedpans can be used for either urination or defecation. A fracture bedpan can be used for any client.

Which of the following situations warrant urinary catheterization? Select all that apply a) A client is unable to mobilize to the bathroom following abdominal surgery. b) A patient with an enlarged prostate is unable to void. c) A client is in septic shock and highly unstable. d) A sterile urine specimen is needed from an acutely confused client. e) A client has developed a urinary tract infection.

Ans: B,C,D Reasons for urinary catheterization include monitoring acutely ill clients, obtaining sterile urine specimens from clients who cannot otherwise provide them, and relieving urinary retention. The presence of a urinary tract infection does not necessarily indicate a need for catheterization. A client who is immobile should be introduced to the use of a bedpan or commode.

A woman informs the nurse that when she is experiencing stress it is difficult to void, and wonders why this happens. What is the nurse's best explanation? a) "You require greater privacy to void." b) "What medications are you taking?" c) "Stress causes the muscles to become tense." d) "You might have a neurologic condition."

Ans: C A person's muscles may become so tense that relaxation of the perineal muscles does not occur, and voiding is inhibited.

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

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

A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next? A. Report this abnormal finding to the physician. B. Perform another catheterization to verify the amount. C. Document this normal finding for postvoid residual. D. Palpate the abdomen for a distended bladder.

Ans: C Feedback: A postvoid residual (PVR) urine measures the amount of urine remaining in the bladder after voiding. It can be measured by catheterization or a bladder scan. A PVR of less than 50 mL indicates adequate bladder emptying. The nurse would document this normal finding for PVR.

A nurse is educating a client on the amount of water to drink each day. What is the recommended daily fluid intake for adults? A. 1 to 2 (4-oz) glasses per day B. 5 to 6 (6-oz) glasses per day C. 8 to 10 (8-oz) glasses per day D. 16 to 20 (12-oz) glasses per day

Ans: C Feedback: Adults with no disease-related fluid restrictions should drink 2,000 to 2,400 mL (8 to 10 8-oz glasses) of fluid daily. Monitor fluid intake for those that are high in caffeine, sodium, and sugar.

A client is taking diuretics. What should the nurse teach the client about his urine? A. Urinary output will be decreased. B. Urinary output will be increased. C. Urine will be a pale yellow color. D. Urine may be brown or black.

Ans: C Feedback: Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The nurse should inform the client about this side effect of the medication.

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? A. The diminished ability of the kidneys to concentrate urine may result in urinary tract infection. B. Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency. C. Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. D. Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence

Ans: C Feedback: 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.

A nurse is performing intermittent closed-catheter irrigation for a patient with an indwelling catheter. After attaching the syringe to the access port on the catheter, the nurse finds that the irrigant will not enter the catheter. What intervention would the nurse appropriately perform next? a. Apply pressure to the catheter to force the solution into the catheter. b. Disconnect and reconnect the drainage system quickly. c. Notify the primary care provider. d. Change the catheter.

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

A nurse is assessing the urine on a newborn's diaper. What would be a normal assessment finding? A. Scanty to no urine B. Highly concentrated urine C. Light in color and odorless D. Dark in color and odorous

Ans: C Feedback: Infants are born with little ability to concentrate urine. An infant's urine is usually very light in color and without odor until about 6 weeks of age, when the nephrons are able to control reabsorption of fluids and effectively concentrate urine. Infants do not normally have scanty, highly concentrated, or dark and odorous urine.

A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? a. Teach the patient that incontinence is a normal occurrence with aging. b. Ask the patient's family to purchase incontinence pads for the patient. c. Teach the patient to perform Kegel exercises at regular intervals daily. d. Insert an indwelling catheter to prevent skin breakdown.

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

A nurse is preparing to catheterize a female client. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra? A. Has different innervation B. No connection with bladder C. Shorter in length D. Longer in length

Ans: C Feedback: The anatomy of the urethra differs in males and females. The male urethra is about 51/2 to 61/4 inches (13.7 to 16.2 cm) long. The female urethra is about 11/2 to 21/2 inches (3.7 to 6.2 cm) long. This difference is important in terms of catheterization and risk for infection.

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

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

A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching? A. "I need to tell you that I am having my menstrual period." B. "I will void into the specimen bottle you gave me." C. "I will keep the toilet paper in the specimen." D. "I will be sure that no stool is included in my urine."

Ans: C Feedback: Urine for a routine urinalysis does not have to be sterile. Ask the client to void into a clean receptacle and avoid contamination with stool. Note on the request form if a woman is having her menstrual period. Instruct clients not to put toilet paper into the urine because this makes analysis more difficult.

A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. Which is a recommended guideline for initiating this training? A. The child should be able to hold urine for four hours. B. The child should be between 18 and 24 months old. C. The child should be able to communicate the need to void. D. The child does not need the desire to gain control of voiding.

Ans: C Feedback: 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 two 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 nurse is performing an intermittent closed catheter irrigation on a client and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's response to this situation? a) Wait three hours and repeat irrigation. b) Prepare to change the catheter. c) Repeat the irrigation. d) Notify the primary care provider

Ans: C 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.

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. The nurse reviews measures to follow to promote health and decrease the risk of contracting a UTI. Which measure is appropriate for the client to follow? a) Wipe the perineal area from the rectal area to the urethra. b) Take baths instead of showers. c) Drink two glasses of water before and after sexual intercourse. d) Wear satin or silk underwear that hugs the skin tightly.

Ans: C 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; drinking two glasses of water before and after sexual intercourse; showering rather than bathing; wearing cotton underwear; avoiding tight, constricting clothing; and drinking cranberry or blueberry juice daily.

A client has a urinary tract infection. The client is told to take phenazopyridine (Pyridium) to decrease urinary discomfort. The client should be instructed that her urine will turn what color? a) Blue b) Pink c) Orange d) Green

Ans: C Phenazopyridine (Pyridium) causes urine to turn bright orange.

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

Ans: C Polyuria means greater than normal urinary elimination. It may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects (e.g., coffee, tea), or taking certain medications actually can increase urination. Oliguria is inadequate elimination of urine. Anuria means the absence of urine. Dysuria is difficult or uncomfortable voiding

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

Ans: C Stress incontinence is caused by pelvic floor muscle weakness. Urge incontinence is the inability to suppress urination after sensing the need to do so; many physical and psychological issues can be related to this problem. Overflow incontinence is related to overdistention, or overflow, of the bladder. Causes of functional incontinence include environmental barriers, physical limitations, memory loss, and disorientation.

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

Ans: C The nurse could describe the client's condition as the loss of urine without any identifiable pattern or warning. Stress incontinence can be described as loss of a small amount of urine when intra‐abdominal pressure rises; whereas, urge incontinence can be described as the need to void is perceived frequently with a short‐lived ability to sustain control of flow. Functional urinary incontinence can be described as the loss of control over urination because a toilet is not accessible.

A client has been NPO after midnight for surgery. It is 11 AM and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color? a) Pale yellow b) Colorless c) Dark amber d) Tea colored

Ans: C Urine may be dark amber or orange‐brown if it is very concentrated secondary to a decreased fluid intake. Urine is lighter than normal if it is diluted. Foods or drugs can also alter the color of urine. Tea‐colored or very dark urine is a sign of dehydration.

A nurse is preparing a brochure to teach patients how to prevent urinary tract infections. Which teaching points would the nurse include? Select all that apply. a. Wear underwear with a synthetic crotch. b. Take baths rather than showers. c. Drink eight to ten 8-oz glasses of water per day. d. Drink a glass of water before and after intercourse and void afterwards. e. Limit caffeine-containing beverages. f. Drink 10 oz of cranberry or blueberry juice daily.

Ans: C,E,F Feedback: It is recommended that a healthy adult drink eight to ten 8-oz glasses of fluid daily, limit caffeine because it is irritating to the bladder mucosa, and drink 10 oz of cranberry or blueberry juice daily to help prevent bacteriuria. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse.

The nurse is preparing to assess a client's postvoid residual using a bladder scanner. Arrange the following steps in the correct order. 1. Position scanner head with directional arrow pointing to the head. 2. Aim scanner head toward coccyx and activate scan. 3. Press scanner head onto the skin 1 to 1.5 inches above the symphysis pubis. 4. Verify that screen crossbars fall within bladder image. 5. Press the appropriate gender button. 6. Observe and record the volume measurement on the screen.

Ans: Correct order is: 5. Press the appropriate gender button. 1. Position scanner head with directional arrow pointing to the head. 3. Press scanner head onto the skin 1 to 1.5 inches above the symphysis pubis. 2. Aim scanner head toward coccyx and activate scan. 4. Verify that screen crossbars fall within bladder image. 6. Observe and record the volume measurement on the screen.

A nurse collects a clean‐catch specimen from a client at a health care facility. Which of the following statements describes a clean‐catch urine sample? a) A sample of fresh urine collected in a clean container b) A sample of urine collected over a period of 24 hours c) A sample of urine collected in a sterile environment d) A sample of urine that is considered sterile

Ans: D 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 collecting a routine urinalysis on a client presenting to the emergency room with abdominal pain. Which of the following is true regarding this specimen? a) The nurse will obtain a sterile specimen and send it to the lab. b) The nurse will obtain a nonsterile specimen, allow it to settle at room temperature for two hours, and then send it to the lab. c) The nurse will obtain a sterile specimen and allow it to settle at room temperature for two hours. d) The nurse will obtain a nonsterile specimen and send it to the lab.

Ans: D 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.

The nurse should instruct the female client who has experienced two urinary tract infections within the past year to do what? a) Avoid drinking cranberry juice. b) Apply powder to the perineum. c) Use shower gels and bubble bath. d) Void following sexual intercourse.

Ans: D Factors that increase the incidence of urinary tract infections include incorrect wiping of the anal area after bowel movements; sexual intercourse, which can bring perineal microorganisms into closer contact with the urethral meatus; and any procedure that places an object in the urethra or bladder for diagnostic procedures or therapeutic reasons.

A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia a. The stoma is hard and dry. b. The stoma is a pale pink color. c. The stoma is swollen. d. The stoma is a purple-blue color.

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

A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill? A. Deflate the balloon by aspirating the fluid. B. Ask the client to take several deep breaths. C. Tell the client burning may initially occur. D. Wash hands and put on gloves.

Ans: D Feedback: Although all the steps listed are correct, the first step of any skill involving body fluids is to wash hands and don gloves.

A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine? A. Compare the amount of output with intake. B. Use a clean measuring cup for each voiding. C. Tell the client to wash the urethra before voiding. D. Wear gloves when handling a client's urine.

Ans: D Feedback: Gloves are required when handling urine to prevent exposure to pathogenic microorganisms or blood that may be present in the urine. In addition, goggles are also worn if there is a concern of urine splashing.

Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult patient. Which information is least important for the evaluation process? a. The incontinence pattern b. State of physical mobility c. Medications being taken d. Age of the patient

Ans: D Feedback: Incontinence is not a natural consequence of the aging process. All the other factors are necessary information for the plan of care.

A client has been taught how to do Kegel exercises. What statement by the client indicates a need for further information? A. "I understand these will help me control stress incontinence." B. "I know this is also called pelvic floor muscle training." C. "I will do these 30 to 80 times a day for two months." D. "I will contract the muscles in my abdomen and thighs."

Ans: D Feedback: 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 school nurse is educating a class of middle-school girls on how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information? A. "I will take showers rather than baths." B. "I will wear underpants with cotton crotches." C. "I will tell my parents if I have burning or pain." D. "I will wipe back to front after going to the toilet

Ans: D Feedback: Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include drying the perineal area after urination or defecation from the front to the back (or from urethra to rectum).

A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? A. Anuria B. Oliguria C. Polyuria D. Dysuria

Ans: D Feedback: The nurse could document the client's condition as dysuria, which is difficulty or discomfort when voiding. Dysuria is a common symptom of trauma to the urethra or bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24 hours. Oliguria indicates inadequate elimination of urine. Polyuria is the term used to indicate greater than normal urinary volume, and may accompany minor dietary variations.

A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client's anxiety? A. "We do these procedures every day, so you don't need to worry." B. "I have had this done to me, and it only hurt for a little while." C. "Why are you so worried? Do you think you have a tumor?" D. "Let me explain to you what they do during this procedure."

Ans: D Feedback: Various diagnostic procedures, typically performed in a hospital operating room or outpatient facility, are used to study the urinary system. Nurses are responsible for preparing the client and giving aftercare. Explaining the procedure helps reduce the client's anxiety.

A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen? A. Pour urine from the collecting bag. B. Remove the catheter and ask the client to void. C. Aspirate urine from the collecting bag. D. Aspirate urine from the collection port

Ans: D Feedback: When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should always be obtained from the catheter itself using the special collection port.

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

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

A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. a. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. b. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. c. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. d. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. e. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. f. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.

Ans: D,E,F Feedback: A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis.

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

Ans: The correct order is 1. Open sterile catheterization tray using sterile technique. 5. Don sterile gloves. 3. Open all sterile supplies. 4. Clean each labial fold, then the area directly over the meatus. 2. Slowly insert the lubricated catheter into the urethra. 6. Advance the catheter until there is a return of urine.

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

The UAP reports that a client on furosemide has voided 4000 mL in a 24-hour period. What is the appropriate nursing action?

Contact the health care provider to decrease furosemide. 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 healthcare provider to decrease furosemide. Documenting the finding as normal, increasing IV fluids, and administering an additional dose of furosemide are not appropriate nursing actions.

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.

Daytime continence is normal in a 3-year-old child. 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 is educating a client with an ileal conduit about the effects of food and fluid intake on the amount and quality of urine produced by the body. Which teaching points should the nurse include? Select all that apply.

Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. Fluid overload leads to excretion of a large quantity of dilute urine. Consumption of caffeine-containing beverages (cola, coffee, and tea) leads to increased urine production due to their diuretic effect. Ingestion of certain foods, such as asparagus, onions, and beets, may lead to alterations in the odor or color of urine.

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 is caring for a client with urinary incontinence who has a prescription for a postvoid residual (PVR) collection. 45 mL of amber urine is returned via PVR. Which appropriate action would the nurse take with this data collection?

Document the finding. A PVR of less than 50 mL indicates the bladder is adequately emptying, so the nurse should document the findings. Since this normal there is no need to encourage more fluids, re-catheterize the client, or perform a bladder scan.

A female infant has voided for the first time. The nurse notes the urine is light pink tinged. What actions by the nurse are indicated?

Document the findings as normal, recognizing that they have been caused by an accumulation of uric acid crystals.

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.

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. The nurse reviews measures to follow to promote health and decrease the risk of contracting a UTI. Which measure is appropriate for the client to follow?

Drink two glasses of water before and after sexual intercourse.

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

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

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?

Ensure proper positioning of the scanner head and rescan.

A nurse is caring for a client with an external condom catheter. What is a guideline for applying and caring for this type of catheter?

Fasten the condom securely enough to prevent leakage without constricting the blood vessels.

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 Definitions of Different Incontinence episodes: 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. laughs & coughs 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.

The health care provider has ordered a Foley catheter for a male client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. What is the appropriate nursing intervention?

Inform the client that the health care provider can be contacted to discuss other catheter options. The nurse will tell the client that another type of catheter, such as a condom catheter, may be ordered at the discretion of the health care provider. The nurse should not implement bathroom privileges or straight catheterization without a health care provider's order. It is unethical and inappropriate to continue to place the catheter without the client's consent.

The nurse is caring for a male client who has a urinary obstruction and is not a candidate for surgery. Which intervention will the nurse prepare the client for?

Insertion of a urologic stent

A home care nurse visits a client diagnosed with depression who informs the nurse that he has been prescribed amitriptyline. What would the nurse include when educating the client about the effects of this medication?

It causes urine to turn blue-green.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

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

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?

Keep muscles contracted for at least 10 seconds.

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?

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 3-4 times daily for 2 weeks to 1 month.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realize the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

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?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Correct response:

The nurse is attempting to insert a urinary catheter into a female client's bladder and realize the catheter has been inserted into the vagina. Which action is most appropriate?

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

The nurse is assisting an older adult client into position for a sigmoidoscopy. Which position would the nurse place the client in?

Left lateral

S3

Left-to-right shunt (VSD, PDA, ASD), mitral regurgitation, LV failure (CHF) 3rd heart sound

A nurse assesses the urine of a client who is using a bedpan and finds that it is a dark brown color. What medication might be causing this effect?

Levadopa

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?

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

The nurse has an order to check the patient's post -void residual. How would the nurse carry this out?

Measure the amount of urine in the bladder using a bladder scan.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron

A client is suspected of having a disease process affecting the functional unit of the kidney. Which stucture is most likely involved?

Nephron

A client is suspected of having a disease process affecting the functional unit of the kidney. Which stucture is most likely involved

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 needs to administer an enema to a client to lubricate the stool and intestinal mucosa to make stool passage more comfortable. Which type of enema should the nurse administer?

Oil-retention

An older adult client is experiencing urinary retention. What age-related physiologic change does the nurse discuss with the client that may be a contributing factor?

Older adults may have a decrease in contraction of the bladder.

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

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

A 65-year-old client confides experiencing urinary incontinence to the nurse. 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?

Openly discuss adult undergarments with the client.

A nurse maintaining continuous bladder irrigation on a client notes that hourly drainage is less than amount of irrigation being given. Which interventions would be appropriate in this situation? Select all that apply.

Palpate for bladder distention. Check to make sure that the tubing is not kinked. If return flow remains decreased, notify the health care provider.

4, 1, 6, 5, 3, 2

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

A nurse is caring for a client who is catheterized following surgery of the prostate. When caring for the client, the nurse performs a continuous irrigation of the catheter. Which intervention should the nurse perform when providing continuous irrigation?

Prime the tubing with the solution. The nurse must prime the tubing with the irrigation solution to ensure that no air enters the system. The nurse should hang the sterile irrigating solution from an IV pole, rather than place it on the bed, to allow it to flow freely. The nurse empties the balloon with a syringe and also cleans the urinary meatus when removing the catheter—not when irrigating the catheter.

The client is preparing to obtain a clean-catch midstream urine specimen. List in order the steps needed to complete the diagnostic test.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into stool. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which of the following would the nurse document as an abnormal finding?

Reddened perineal skin

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?

Reddened perineal skin

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which of the following would the nurse document as an abnormal finding?

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.

Which urinary care teaching will the nurse provide to a young adult female client?

Refrain from douching unless ordered by a health care provider.

The nurse needs to collect a stool specimen for culture from a client. The client passed stool into the toilet instead of using the collection container. What is the next step for the nurse?

Reinstruct the client on use of collection container for next bowel movement.

A client who had an open hysterectomy 2 days ago is ambulating around the unit four 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?

Request an order for catheter discontinuation from the health care provider.

A nurse is caring for an older adult client who has been prescribed a condom catheter. What potential problems related to the use of a condom catheter should the nurse monitor in the client? Select all that apply.

Restricted blood flow to the glans tissue Excoriation of the skin in the glans area Kinks in tubing that encourage backflow of urine

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

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

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

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

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

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

a, b, d, e

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

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

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

A nurse is assessing the bowel elimination of pediatric clients on the unit. Which developmental factors affecting elimination should the nurse consider? Select all that apply.

Some children have bowel movements only every 2 or 3 days. The number of stools that infants pass varies greatly.

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

Stress

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

Stress incontinence

Which is not true of urine color?

The appearance of urine streaked with blood is always abnormal

Which is not true of urine color?

The appearance of urine streaked with blood is always abnormal. Urine may appear cloudy, dark reddish-brown, or streaked with blood when a woman is menstruating.

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?

The birth can cause perineal swelling.

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?

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 nurse is preparing to catheterize a client who is incontinent of urine following bladder surgery. What fact should the nurse keep in mind when performing catheterization?

The bladder normally is a sterile cavity.

The nurse is providing education to a client who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the client?

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

The 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 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

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

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. Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization.

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 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 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 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.

A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?

The largest part of a regular bedpan should be placed under the client's buttocks.

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 selects an 18 French Foley catheter to insert.

The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply.

The nurse gently palpates the client's symphysis pubis. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). The nurse adjusts the scanner head to center the bladder image on the crossbars.

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

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

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

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

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

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

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

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

Which of the following is a recommended guideline when catheterizing the female urinary bladder?

The nurse should lubricate 1 to 2 inches (2.5-5 cm) of the catheter tip and, using the dominant hand, hold the catheter 2 to 3 inches (5-7.5 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 inches [5 to 7.5 cm]) and, once urine drains, advance catheter another 2 to 3 inches (5 to 7.5 cm).

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

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

A nurse assessing an elderly patient finds that the patient has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause?

The nurse would suspect the client had decreased bladder contractility, which lead to the client having issues with urinary retention.

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

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

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

The rounded shelf of a regular bedpan should be placed under the client's buttocks.

The nursing student is performing a focused gastrointestinal assessment. Which action performed by the student would indicate to nurse faculty that further instruction is needed?

The student sequenced from auscultation to inspection, and percussion to palpation.

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.

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

True or False: Use of an indwelling urinary catheter leads to the loss of bladder tone.

True

Use of an indwelling urinary catheter leads to the loss of bladder tone.

True

Use of an indwelling urinary catheter leads to the loss of bladder tone. T or F?

True

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 clients to stand to use a urinal.

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

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

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

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

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

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

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?

Urine culture sensitivity - 100,000/mL

a

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

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

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

A nurse is assessing the stoma of a client with an ostomy. Which intervention should the nurse perform when providing peristomal care to the client to preserve skin integrity?

Wash it with a mild cleanser and water.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority?

Wearing gloves when handling the urine

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

a

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

a (Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.)

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

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

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

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

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

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

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

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

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

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

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle

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

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

The nurse is preparing a client for an intravenous pyelogram. Which nursing actions are performed correctly? Select all that apply.

Withhold food or fluids 12 hours before testing. Give an enema the day of the examination. Obtain client's allergy history. Give a laxative the evening before the examination.

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

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

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

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

For which client would digital removal of stool be contraindicated?

a client recovering from prostate surgery

When assessing an elderly client for constipation, the nurse learns that the client uses mineral oil daily to relieve constipation. Which is an effect of prolonged use of mineral oil to relieve constipation?

affects absorption of fat-soluble vitamins

An infant is born with spina bifida. She may have:

alterations in urinary elimination

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

When a client reports cramping during the administration of a cleansing enema, which nursing action is appropriate?

briefly clamping the tubing while the client breathes deeply

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake

A woman is reporting bladder urgency. It is most important to assess: exercise. weight. caffeine intake. 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.

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

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 The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine; Dark amber urine that is strongly aromatic could indicate dehydration

total incontinence

continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation

A client has been n.p.o. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color?

dark amber

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

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.

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

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 The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine.

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

Descending Colostomy

formed stool typical stool odor stool doesn't irrigate unless diarrhea predictable 2 to 3 times per day emptying lowest risk for fluid/electrolyte imbalances continent do irrigate

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

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

greater than normal urinary volume Polyuria means greater than normal urinary elimination. It may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects (e.g., coffee, tea), or taking certain medications actually can increase urination. Other definitions: Oliguria is inadequate elimination of urine. Anuria means the absence of urine. Dysuria is difficult or uncomfortable voiding.

The nurse will gather which type of solution to administer a cleansing enema to a client who needs to have water drawn into the bowel?

hypertonic saline

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

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.

ascending colostomy

liquid feces cannot be regulated digestive enzymes present

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 urine without any identifiable pattern or warning

oil retention enema

lubricate the stool and intestinal mucosa, easing defecation

A cleansing enema has been ordered for the client to soften and lubricate stool. Which type of solution does the nurse gather?

mineral oil

sigmoid colostomy

more formed stool - left lower quadrant

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a

neurogenic bladder.

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.

The nurse is administering a rectal suppository. How far will the nurse insert the suppository?

past the internal sphincter

Which medical diagnosis is most likely to necessitate testing for fecal occult blood?

peptic ulcer

medicated enema

provide medications absorbed through the rectal mucosa

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:

pus

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 nurse is planning care for a client with a newly placed urostomy. What priority problems will the nurse address and provide interventions for? Select all that apply.

risk for Infection, Impaired urinary elimination

transverse colostomy

soft stool typical stool odor stool damages the skin empties several times per day may or may not be at risk for fluid/electrolytes imbalances may irrigate

functional incontinence

state in which a person experiences an involuntary, unpredictable passage of urine

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

straight catheter

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

straight catheter Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters

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

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?

stress

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

stress

The health care provider prescribes a long-term continuous drainage system to monitor a chronically ill client. What type of catheter would best suit this client's needs?

suprapubic catheter

transient incontinence

temporary or occasional incontinence that is reversed when the cause is treated

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. This assessment finding indicates:

the client is underhydrated.

Upon assessment of the urine in a client's indwelling urinary catheter drain bag, the nurse notes the urine to be dark yellow. This assessment finding indicates:

the client is unhydrated

The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard?

the first voiding of the day

The nurse is caring for a male client with weakness who has been ordered to stay on bed rest for several days. Which method for urinary elimination does the nurse provide?

urinal

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice?

urinal

The nurse is caring for a male client with weakness who has been ordered to stay on bed rest for several days. Which method for urinary elimination does the nurse provide?

urinal The client with weakness who has been ordered to stay on bed rest will benefit from use of a urinal. The client should not be moved to the bedside commode or regular bathroom. A fracture pan may be useful for bowel movements.

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

urinary retention

The nurse should instruct the female client who has experienced two urinary tract infections within the past year to:

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

The nurse is evaluating stool characteristics of an adult client. Which color stool does the nurse identify as abnormal? Select all that apply.

yellow clay colored black

The nurse has an order to obtain a urine specimen from a client with an indwelling Foley catheter. Which of these supplies would the nurse need to gather? (Select all that apply.)

• 10-mL (milliliter) syringe • Sterile specimen container • Antiseptic swab

Carminative

an agent that promotes the passage of flatus from the colon

The proliferation of Clostridium difficile causes:

antibiotic-associated diarrhea.

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 use clean gloves to handle the catheter and other equipment."

A person should void ________ cc/mL per hour

30

No bowel sounds on lower left quadrant

BS absent LLQ BS active x3

Which is true regarding the normal urination?

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

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?

Check electronic health record for medical order

Colcicine

Colcrys Gout, familial Mediterranean fever

large vs small volume enema

Large - entire colon small - lower, sigmoid colon

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice?

Urinal

mixed incontinence

combination of stress and urge incontinence

The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard?

the first voiding of the day The nurse would discard the first void of the day. The bladder has collected urine that has been produced by the kidneys overnight. The first voided urine of the day is usually more concentrated than other urine excreted during the day. Because the first urine of the day is not fresh, but rather an accumulation of a number of hours of kidney output, this urine may or may not be used as a specimen for certain tests.

stress incontinence

the inability to control the voiding of urine under physical stress such as running, sneezing, laughing, or coughing

ileostomy

the surgical creation of an artificial excretory opening between the ileum, at the end of the small intestine, and the outside of the abdominal wall

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

Which type of incontinence is caused by an overactive detrusor muscle causing involuntary bladder contractions?

urge

pyelogram

x-ray of the renal pelvis

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

Check health record for provider's order.

A client could experience increased urination when using which classification of medication?

Cholinergic agents

The health care provider notifies a client of a diagnosis of glycosuria. When the provider leaves the room, the client states to the nurse, "I don't know what glycosuria means." What is the appropriate nursing response?

"Laboratory findings indicate there is glucose in your urine."

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?

"Discard your first urine and begin the collection after that." 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. Which of the following would be an appropriate question for the nurse to ask the client

"How frequently do you urinate each day?" 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.

A parent brings a 2-year-old child in to the clinic for a wellness check-up and informs the nurse that toilet training is not going well. The parent states,"I thought it would be easy to toilet train for bowel movements, but my child is still having accidents." What is the best response by the nurse? *"You are putting too much pressure on yourself and your child to toilet train." *"Children vary in their readiness but daytime bowel control may be attained at 30 months." *"There may be something wrong since your child should be toilet trained by 2 years-old." *"There is nothing to worry about. Just keep the child in diapers until they stop having accidents."

*"Children vary in their readiness but daytime bowel control may be attained at 30 months."

The nurse is teaching the Crede maneuver to a client who has difficulty urinating. Which nursing teaching is appropriate?

"Bend forward and apply pressure over your bladder."

Which medication causes constipation? *Magnesium antacids *Bisacodyl *Aspirin *Iron supplements

*Iron supplements

A woman is reporting bladder urgency. It is most important to assess: *exercise. *weight. *caffeine intake. *vitamin supplements.

*caffeine intake.

Which medical diagnosis is most likely to necessitate testing for fecal occult blood? *Peptic Ulcer *Chronic Constipation *Cirrhosis of the Liver *Gastroesophageal Reflux Disease (GERD)

*Peptic Ulcer

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a: *cystocele. *enuresis. *overactive bladder. *neurogenic bladder.

*neurogenic bladder.

A client is preparing to give a clean-catch specimen. Which instruction will the nurse provide?

After the initial stream is initiated, collect the sample.

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?

Fasten the condom securely enough to prevent leakage without constricting blood flow.

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

overflow incontinence

over distention of bladder

A client's last bowel movement was 4 days ago and oral laxatives and dietary changes have failed to prompt a bowel movement. How should the nurse position the client in anticipation of administering a cleansing enema? *left side-lying *prone *right side-lying *supine

*left side-lying

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 Advance the catheter until there is a return of urine. 4 Inflate the balloon with the correct amount of sterile saline. 5 Discard used supplies.

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

The nurse is preparing to assess a client's postvoid residual using a bladder scanner. Place the following steps in the correct order. Use all options. 1 Press the appropriate gender button. 2 Position the scanner head with directional arrow pointing to the head. 3 Press scanner head onto the skin 1 to 1.5 inches (2.5 to 3.75 cm) above the symphysis pubis. 4 Aim the scanner head toward the coccyx and activate the scan. 6 Observe and record the volume measurement on the screen. 5 Verify that screen crossbars fall within the bladder image.

1-Press the appropriate gender button. 2- Position the scanner head with directional arrow pointing to the head. 3-Press scanner head onto the skin 1 to 1.5 inches (2.5 to 3.75 cm) above the symphysis pubis. 4-Aim the scanner head toward the coccyx and activate the scan. 5-Verify that screen crossbars fall within the bladder image. 6-Observe and record the volume measurement on the screen.

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24-hour specimen

After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion?

Hyperactive bowel sounds

A nurse is performing a physical assessment of a client's urinary system. Which nursing actions are appropriate during this assessment? Select all that apply.

If using a bedside scanner, place the client in a supine position. Inspect the urethral orifice for any signs of inflammation, discharge, or foul odor. Retract the foreskin of an uncircumcised male client to visualize the meatus. The nurse assess the client's urine for color, odor, clarity, and the presence of any sediment.

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?

Acute confusion

A student nurse is preparing to administer a client's ordered large-volume enema. What action should the nurse perform during this skill?

Administer the solution gradually over 5 to 10 minutes.

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.

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 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.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

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.

The nurse is caring for a client who reports having cloudy, foul-smelling urine. Which other symptoms does the nurse anticipate that the client has?

Burning and frequency The nurse anticipates that the client has a urinary tract infection (UTI), which is characterized by cloudy, foul-smelling urine, burning, and frequency.

Which symptom will have a great impact on the extracellular fluid for water conservation?

Burns 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 (sweating) secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.

The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?

Check electronic health record for medical order.

A client could experience increased urination when using which classification of medication?

Cholinergic agents 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.

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.

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 nurse is testing a client's stool specimen for occult blood. Which are responsibilities of the nurse for this testing? Select all that apply.

Collecting the specimen Handling the specimen Transporting the specimen Teaching the client about the test

To promote drainage of a client's Foley catheter, which intervention would be most important for the nurse to implement?

Confirming the catheter tubing is not lying under the client

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.

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.

The UAP reports that a client on furosemide has voided 4000 mL in a 24-hour period. What is the appropriate nursing action?

Contact the health care provider to decrease furosemide.

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

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

urge incontinence

involuntary leakage of urine with a sudden, strong desire to urinate

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 Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing

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

Anthelmintic

substance that works against intestinal worms