Chapter 46: Urinary Elimination (Urinary Elimination and the Nursing Process)

The nurse is caring for a patient with urinary incontinence. Which actions should the nurse perform to promote comfort for the patient? Select all that apply.

*A. Change dressings and linens when wet.* B. Limit fluid intake. *C. Use absorbent pads.* D. Increase coffee intake. *E. Catheterize the patient with orders from the health care provider.* Rationale: Wet dressings and linens should be changed to prevent skin impairment and promote comfort. Absorbent pads can be used to keep the patient dry. The patient can be catheterized after obtaining orders from the health care provider. Limiting fluid intake increases the risk of dehydration and urinary tract infection. Coffee is an irritant to the bladder and its intake should be limited. Pg. 1104

The nurse takes an order to obtain a post-void residual for a patient via catheterization. Which is the best method to obtain this measurement?

*A. Intermittent catheterization* B. Long-term indwelling catheterization C. Short-term indwelling catheterization D. Medium-term indwelling catheterization Rationale: Intermittent catheterization is used when evaluating the residual urine following urination. The investigation requires measurement of urine remaining in the bladder after voiding. Intermittent catheterization prevents the risk of infection. Long-term catheterization is done in patients with urinary retention. It may also be done for patients with recurrent episodes of urinary infections, skin breakdown, and terminal illness. Short-term catheterization is required for obstructive conditions, surgical repair of bladder and urethra, prevention of urethral obstruction, and bladder irrigation. There is no such thing as medium-term indwelling catheterization. Pg. 1119

A nurse instructs an elderly patient to restrict fluid intake 2 hours before bedtime. Which complication is the nurse trying to reduce?

*A. Nocturia* B. Urinary retention C. Urinary tract infection D. Stress urinary incontinence Rationale: To reduce nocturia, the patient should be advised to restrict fluid intake 2 hours before bedtime. Intermittent catheterization may be used to manage mild urinary retention. The nurse should instruct the patient to follow good perineal hygiene practices to prevent urinary tract infections. To manage stress urinary incontinence, the nurse should teach the patient pelvic muscle exercises. Pg. 1107

The patient's urine specific gravity is 1.05. The urine tests positive for ketone bodies. Which could be possible causes? Select all that apply.

*A. Starvation* B. Dilute urine *C. Dehydration* D. Overhydration *E. Diabetes mellitus* Rationale: Presence of ketone bodies supports the possibility of starvation. Specific gravity would be increased if the patient were dehydrated. Increased specific gravity and ketone bodies in the urine also support the possibility of diabetes mellitus. A high specific gravity and the presence of ketone bodies do not indicate urine dilution or overhydration. Study Tip: The more concentrated the urine, the higher its specific gravity. The specific gravity of distilled water is 1.000, and normal urine may range from 1.010 to 1.030. Therefore, a specific gravity of 1.050 is high, indicating the urine is more concentrated than normal, or lower in water content than normal. A dilute urine would have a lower-than-normal specific gravity. You also know the patient is not overhydrated. Thus you can eliminate the choices "Dilute urine" and "Overhydration," Pg. 1113

A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be most beneficial in assisting the patient to void?

*A. Suggest he stand at the bedside.* B. Stay with the patient. C. Give him the urinal to use in bed. D. Tell him that, if he doesn't urinate, he will be catheterized. Rationale: A man voids more easily in the standing position. Pg. 1119

The patient states that she "loses urine" every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. Which statement by the patient indicates the need for further teaching?

A. "I will perform my Kegel exercises every day." B. "I joined Weight Watchers." *C. "I drink two glasses of wine with dinner."* D. "I have tried urinating every 3 hours." Rationale: Alcohol is a bladder irritant. It increases urine production and causes uncontrolled bladder contractions. Pg. 1105

Which of a student nurse's statements regarding urinary incontinence requires correction?

A. "Urinary incontinence is common in older adults." B. "Urge incontinence and stress incontinence are common forms of urinary incontinence." C. "Urinary incontinence is characterized by any involuntary loss of urine." *D. "Mixed incontinence is a combination of stress and functional incontinence."* Rationale: Mixed incontinence is a combination of stress and urge, not functional, incontinence. Urinary incontinence is common in older adults. Urge incontinence and stress incontinence are common forms of urinary incontinence that are characterized by any involuntary loss of urine. Pg. 1103, 1105

What instructions regarding bladder training should be included in the teaching plan for the family of a patient who is incontinent because of a stroke?

A. "Use an indwelling catheter at night to prevent accidents." *B. "Offer the patient the commode or urinal every 2 hours."* C. "Decrease the patient's oral fluid intake to 1 L per day." D. "Instruct the patient to hold the urine as long as possible to restore bladder tone." Rationale: To begin a bladder-training program, the nurse should teach the family to offer the patient the commode, bedpan, or urinal every 2 hours. Making this offer frequently enough prevents accidents and establishes a routine. Using an indwelling catheter in a home setting increases the possibility of trauma or infections to the urethra and bladder. Decreasing the patient's fluid intake could cause secondary complications of dehydration and electrolyte imbalance. The patient is incontinent so is unable to hold the urine. Pg. 1119

A patient tells a nurse, "I lose small amounts of urine while coughing, laughing, exercising, and walking but not at night while sleeping." Which of the nurse's responses is most appropriate?

A. "You may require intermittent catheterization." B. "You should avoid caffeine, artificial sweeteners, and alcohol." *C. "I'll teach you pelvic muscle exercises that you can perform regularly to address the problem."* D. "You can perform urge-inhibition exercises to obtain relief from symptoms of urinary incontinence." Rationale: Loss of a small volume of urine while coughing, laughing, exercising, and walking but not at night while sleeping, is characteristic of stress incontinence. This type of incontinence can be managed with pelvic muscle exercises. Overflow incontinence is associated with chronic retention of urine, and patients with this type of incontinence may require intermittent catheterization. Patients with urge incontinence may be instructed to avoid bladder irritants such as caffeine, artificial sweeteners, and alcohol. Urge-inhibition exercises may also help relieve symptoms associated with urge incontinence, not stress incontinence. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer. Pg. 1104

Which patient is most likely to exhibit symptoms such as dysuria, urgency, frequency, and nocturia?

A. A patient with kidney failure B. A patient receiving diuretic therapy *C. A patient with a urinary tract infection* D. A patient with uncontrolled diabetes mellitus Rationale: Dysuria, urgency, frequency, and nocturia are symptoms that may be exhibited by patients with urinary tract infections. A patient with kidney failure may experience oliguria. Patients receiving diuretic therapy and those with uncontrolled diabetes mellitus may exhibit polyuria. Test-Taking Tip: Sometimes the reading of a question in the middle or toward the end of an exam may trigger your mind with the answer or provide an important clue to an earlier question. Pg. 1110

A 70-year-old woman complains of involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when she coughs. The nursing assessment reveals that the patient is obese, has had three pregnancies, and has already gone through menopause. Which nursing interventions would be helpful to this patient in reducing incontinence? Select all that apply.

A. Advise the patient to suppress coughs. *B. Teach the patient Kegel exercises.* *C. Advise the patient to avoid caffeinated drinks.* *D. Stress the importance of losing weight.* E. Encourage lifting heavy weights to increase muscle strength. Rationale: Kegel exercises increase the strength of muscles around the urethra and help to reduce stress incontinence. Losing weight helps to reduce stress incontinence. Cough is a reflex activity and is difficult to control voluntarily. Caffeinated drinks have a diuretic effect and increase stress incontinence. Lifting heavy weights increases abdominal pressure and thus increases incontinence; therefore, this activity should be avoided. Pg. 1105

A nurse is assisting the primary health care provider in assessing a patient with altered urinary elimination. After assessing the patient, the primary health care provider suspects that the patient has an obstruction of the ureters. Which diagnostic test does the nurse expect the patient to undergo?

A. Cystoscopy B. Abdominal roentgenogram C. Ultrasound of the urinary bladder *D. Axial computed tomographic scan* Rationale: An axial computed tomographic scan is commonly used to identify anatomic abnormalities, renal tumors and cysts, calculi, and obstruction of the ureters. Cystoscopy is an invasive procedure used to detect bladder tumors and obstruction of the bladder outlet and urethra. An abdominal roentgenogram is commonly ordered to detect and measure the size of urinary calculi. An ultrasound scan of the urinary bladder is helpful in the measurement of the post void residual volume. Pg.1114

A 70-year-old woman complains of involuntary passage of urine. The leakage of urine occurs in small amounts and is more frequent when she coughs. The nursing assessment reveals that the patient is obese, has had three pregnancies, and has already gone through menopause. The nurse understands that the patient is at increased risk of developing urinary tract infection. Which nursing interventions are helpful to prevent a urinary tract infection in the patient? Select all that apply.

A. Emphasize reduced fluid intake. *B. Emphasize wearing cotton underwear.* C. Emphasize the need for continuous bladder catheterization. *D. Promote complete emptying of bladder by double voiding.* *E. Emphasize the importance of perineal hygiene.* Rationale: Cotton underwear absorbs moisture and helps to keep the skin on the perineal area dry. Residual urine in bladder promotes bacterial growth. Complete voiding reduces the risk of developing a urinary tract infection and may be achieved by double voiding. Perineal hygiene is important in preventing a urinary tract infection. The urethral meatus should be cleaned after each void or bowel movement. Adequate fluid intake helps to flush the microorganisms from the urinary tract and prevent infection. Catheterization increases the risk of bladder infections and should be avoided. Pg. 1118

A postoperative patient has difficulty voiding after surgery and is feeling "uncomfortable" in the lower abdomen. Which action should the nurse implement first?

A. Encourage fluid intake. B. Administer pain medication. C. Catheterize the patient. *D. Turn on the bathroom faucet as the patient tries to void.* Rationale: The sound of running water helps many patients to void through the power of suggestion. Pg. 1118

The nurse is reviewing laboratory results for a patient and notices the urine tested positive for ketones. Which underlying factors may lead to the presence of urinary ketone bodies? Select all that apply.

A. Epilepsy *B. Starvation* *C. Dehydration* D. Hyperthyroidism *E. Uncontrolled diabetes mellitus* Rationale: Ketones are produced as a by-product when the body uses fat for energy production. When a patient is not taking in adequate amounts of carbohydrate, such as in starvation, the body uses other sources for energy. Dehydration can also lead to ketonuria. A patient with uncontrolled diabetes mellitus breaks down fatty acids for energy. Epilepsy and hyperthyroidism are not associated with the presence of ketone bodies in urine. Epilepsy is a disease that affects the nervous system, and hyperthyroidism affects the endocrine system. Pg. 1113

What should the nurse include in the plan of care for a patient with urge urinary continence?

A. Helping the patient learn efficient and safe toilet transfers B. Helping the patient with leg-strengthening exercises *C. Helping the patient strengthen the pelvic floor muscles and learn fluid and food modifications* D. Helping the patient obtain assistive devices for the home that are covered by insurance Rationale: While caring for a patient with urge urinary continence, the nurse should help the patient strengthen the pelvic floor muscles, learn techniques to inhibit the urinary urge, and learn fluid and food modifications. The other actions are the responsibilities of other health care professionals. It is the responsibility of an occupational therapist to help the patient learn efficient and safe toilet transfers. It is the responsibility of a physical therapist to help the patient with leg-strengthening exercises. A social worker should help the patient obtain assistive devices for the home that are covered by insurance. Pg. 1118

Which intervention is most appropriate for a patient with functional urinary incontinence?

A. Insert an indwelling catheter. B. Increase fluid intake to flush the kidneys. *C. Provide normal fluid intake and establish a toilet schedule.* D. Restrict fluid intake to decrease the episodes of incontinence. Rationale: For physiological health, a patient must maintain normal fluid intake. A toileting schedule based on the patient's elimination patterns can help reduce episodes of incontinence. Catheters are used as a last choice, because of the potential for infection and body self-image issues. Fluid intake should be kept at normal levels; there is no need to increase it. Restricting the fluid intake may cause dehydration. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point. Pg. 1119

The nurse notes that the patient's indwelling catheter bag has been empty for 4 hours. What is the priority action?

A. Irrigate the indwelling catheter. *B. Check for kinks in the tubing.* C. Notify the health care provider. D. Assess the patient's intake. Rationale: Kinks in tubing prevent flow of urine. To keep the drainage system patent, check for kinks or bends in the tubing. Pg. 1121

The nurse notices pus in the catheter of a patient who had an indwelling catheter inserted 4 days ago. Which nursing measure is appropriate for this patient?

A. Irrigating the catheter with 10 mL of water *B. Replacing the catheter with a new one* C. Irrigating the catheter with antiseptic solution D. Milking the catheter from proximal end to distal end Rationale: The nurse should replace an indwelling catheter when pus is noted in it. The contaminated catheter should be removed and replaced with a new catheter. Irrigation causes the pus to go back to the bladder, which worsens the infection. Irrigating with antiseptic solution is appropriate for patients with a bladder infection but without pus in the catheter. Milking the tube is helpful for relieving tubal obstructions within catheters. Pg. 1111

A nurse is caring for a patient with a spinal cord injury who reports an absence of awareness of bladder filling and the urge to void. A family member adds that the patient also sometimes has leakage of urine without awareness. Which nursing intervention is most important for the patient?

A. Placing an indwelling catheter *B. Monitoring for autonomic dysreflexia* C. Encouraging the patient to perform pelvic muscle exercises D. Monitoring the postvoid residual volume according to the health care provider's direction Rationale: Reflex urinary incontinence occurs in patients who have spinal cord injuries and, it is characterized by diminished or absent awareness of bladder filling and the urge to void. The patient may also have leakage of urine without awareness. Patients with reflex urinary incontinence have an increased risk of autonomic dysreflexia, which is a life-threatening condition. This is a medical emergency that requires immediate intervention, so the nurse's most important intervention is to monitor the patient for autonomic dysreflexia and notify the health care provider immediately. Patients with overflow urinary incontinence may require the use of an indwelling catheter. Patients with stress urinary incontinence should be encouraged to perform pelvic muscle exercises. Monitoring the postvoid residual volume according to the health care provider's direction is important when caring for a patient with mild urinary retention associated with overflow urinary incontinence. Pg. 1105

The nurse is reviewing the lab report of a patient. The presence of which substance in the urine hints at the possibility of an abnormality?

A. Protein, 6 *B. Glucose, ++* C. Red blood cells, 2 D. White blood cells, 4 Rationale: A normal urinalysis should not be positive for glucose, because glucose undergoes complete reabsorption. The presence of protein in the urine is acceptable under 8 mg/100 mL. The presence of 2 red cells is acceptable, but there should not be any more than this. A white cell of count 4 is acceptable and does not indicate abnormality. Pg. 1113

The patient is incontinent, and a condom catheter is placed. Which action should the nurse take?

A. Shave the pubic area prior to application. B. Ensure foreskin is in retracted position. *C. Assess the patient for skin irritation.* D. Use sterile technique for placement. Rationale: The nurse should assess the patient for skin irritation, which can occur when the condom is twisted at the drainage tube attachment and obstructs urine drainage. Skin should not be shaved prior to condom application; however, hair can be clipped at the base of the penis as necessary. If patient is uncircumcised, ensure that the foreskin is in the normal nonretracted position. Hand hygiene and glove application is adequate for this procedure. Pg. 1125

A nurse is caring for an elderly patient who has recently started taking an antimuscarinic medication to treat urinary continence. Which nursing intervention is most important in this situation?

A. Teaching pelvic muscle exercises *B. Assessing the patient for mental status changes* C. Reminding the patient to drink adequate amounts of water D. Instructing the patient to restrict fluid intake 2 hours before bedtime Rationale: Antimuscarinic medications may cause cognitive impairment in older adults; therefore, the nurse should assess the patient carefully for mental status changes. Pelvic muscle exercises should be taught to patients with stress incontinence. To promote bladder health through adequate hydration, the nurse should remind patients to drink adequate amounts of water. To reduce nocturia, older adults should be instructed to restrict fluid intake 2 hours before bedtime. Pg. 1107

While caring for a female patient with altered urinary elimination, the nurse instructs the patient to assume a squatting position when voiding. What is the reason behind this recommendation?

A. To prevent infections B. To promote normal micturition *C. To promote complete bladder emptying* D. To help relieve stress urinary incontinence Rationale: The squatting position facilitates complete bladder emptying in female patients. To prevent infections, the nurse promotes adequate fluid intake and perineal hygiene and instructs patients to void at regular intervals. To promote normal micturition, the nurse may instruct the patient to drink adequate amounts of fluid. To help relieve stress urinary incontinence, the nurse may provide pelvic muscle training. Pg.1119

After assessing a patient with urinary incontinence, the health care provider confirms that the patient is at risk for a life-threatening condition that causes severe elevation of blood pressure and pulse rate as well as diaphoresis. Which type of urinary incontinence does this patient have?

A. Transient incontinence B. Stress urinary incontinence *C. Reflex urinary incontinence* D. Urgency urinary incontinence Rationale: Autonomic dysreflexia is a life-threatening condition that causes severe elevation of the blood pressure and pulse rate as well as diaphoresis. Patients with reflex urinary incontinence are at an increased risk for this condition. Transient incontinence, stress urinary incontinence, and urgency urinary incontinence are associated with other conditions. Pg. 1105

The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. What should the nurse teach the patient to do?

A. Use the double-voiding technique. B. Perform Kegel exercises. *C. Use the Credé method.* D. Keep a voiding diary. Rationale: With the Credé method, pressure is put on the suprapubic area with each attempted void. The maneuver promotes bladder emptying by relaxing the urethral sphincter. Pg. 1119