EAQ Unit 6
The nurse is caring for a client in the postanesthesia care unit. The client had a suprapubic prostatectomy for cancer of the prostate and has a continuous bladder irrigation (CBI) in place. Which primary goal is the nurse trying to achieve with the CBI? 1. Stimulate continuous formation of urine. 2. Facilitate the measurement of urinary output. Correct 3. Prevent the development of clots in the bladder. 4. Provide continuous pressure on the prostatic fossa.
A continuous flushing of the bladder dilutes the bloody urine and empties the bladder, preventing clots. Fluid instilled into the bladder does not affect kidney function. Urinary output can be measured regardless of the amount of fluid instilled. The urinary retention catheter is not designed to exert pressure on the prostatic fossa.
A client is transferred to the postanesthesia care unit after undergoing a pyelolithotomy. The client's urinary output is 50 mL/hr. What should the nurse do? Correct 1. Record the output as an expected finding. 2. Encourage the client to drink oral fluids. 3. Milk the client's nephrostomy tube. 4. Notify the primary healthcare provider.
An output of 50 mL/hr is adequate; when urine output drops below 20 to 30 mL/hr, it may indicate renal failure, and the primary healthcare provider should be notified. Encouraging the client to drink oral fluids is contraindicated; the client probably still will be under the influence of anesthesia, and the gag reflex may be depressed. Milking the client's nephrostomy tube is unnecessary because the output is adequate.
A male client reports dysuria, nocturia, and difficulty starting the urinary stream. A cystoscopy and biopsy of the prostate gland have been scheduled. After the procedure the client reports an inability to void. Which action should the nurse take? 1. Insert a urinary retention catheter. Correct 2. Palpate above the pubic symphysis. 3. Limit oral fluids until the client voids. 4. Assure the client that this is expected.
A full bladder is palpable with urinary retention and distention, which are common problems after a cystoscopy because of urethral edema. More conservative nursing methods, such as running water or placing a warm cloth over the perineum, should be attempted to precipitate voiding; catheterization carries a risk of infection and is used as the last resort. Fluids dilute the urine and reduce the chance of infection after cystoscopy and should not be limited. Although urinary retention can occur, it is not expected; the nurse must assess the extent of bladder distention and discomfort.
Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? 1. Pouring warm water over the perineum 2. Ensuring the patency of the catheter Correct 3. Removing the catheter within 24 hours 4. Cleaning the catheter insertion site
Clients who undergo surgery are at a greater risk of acquiring catheter-associated urinary tract infections. Infections can be prevented by removing the catheter within 24 hours, if the client does not need it. Therefore removing the catheter within 24 hours would be the best intervention. While pouring warm water over the perineum helps voiding in the postoperative client and also reduces the chances of infection, this action would not be as beneficial as the former intervention. The catheter should be maintained in its place to avoid leakage and infection. Cleaning the catheter insertion site will definitely reduce the risk of infection, but this action cannot prevent infections if the catheter is inserted for a long time.
2. A client has been admitted with a urinary tract infection. The nurse receives a urine culture and sensitivity report that reveals the client has vancomycin-resistant enterococcus (VRE). After notifying the primary healthcare provider, which action should the nurse take to decrease the risk of transmission to others? 1. Insert a Foley catheter. 2. Initiate droplet precautions. Correct 3. Move the client to a private room. 4. Use a high-efficiency particulate air (HEPA) respirator when entering the room.
Clients with VRE should be moved to a private room to decrease transmission to others. VRE has been identified in the urine, not respiratory secretions. Contact isolation should be implemented. A Foley catheter should not be inserted because it will predispose the client to develop an additional infection. A HEPA respirator is not required when entering the room.
A nurse prepares a client with kidney dysfunction for a cystoscopy. Which nursing intervention would be beneficial? 1. Asking the client to have an adequate evening meal 2. Instructing the client to take oral fluids to increase urine output 3. Performing a bowel preparation with enema the morning before the procedure Correct 4. Asking the client to be NPO (nil per os) after midnight on the night before the procedure
A client who is about to undergo cystoscopy should be NPO (nil per os) after midnight on the night before the procedure. The client should eat a light evening meal. The nurse should instruct the client to take oral fluids after the procedure to increase urine output. A bowel preparation with enemas should be performed the evening before the procedure.
The nurse reviews the medical records of four male clients. Which client will the nurse assess most closely for developing prostate cancer? Correct 1. Black 55-year-old 2.White 45-year-old 3. Asian 55-year-old 4. Hispanic 45-year-old
Cancer of the prostate is rare before age 50 years but increases with age; black men develop cancer of the prostate more often and at an earlier age than white men. Black men develop prostate cancer more often than any other ethnic group. Asian American men have a lower incidence than white men.
A client who was admitted to the hospital with a diagnosis of a renal calculus is successful in passing the stone. The nurse is preparing the client for discharge and should include what in the client's instructions? 1. "Strain all urine." Correct 2. "Increase fluid intake." 3. "Limit dietary potassium." 4. "Maintain bed rest for 24 hours."
Increasing fluid intake [1] [2] prevents stagnation of urine, which reduces the risk of precipitates forming calculi. The client has already passed the stone; straining all urine is unnecessary once calculi are removed or passed. Potassium is not restricted in the diet. The client can return to usual activities because the stone was passed; bed rest is not advised because it causes urine to stagnate, predisposing to calculi formation.
Which urinalysis finding indicates a urinary tract infection? 1. Presence of crystals 2. Presence of bilirubin 3. Presence of ketones Correct 4. Presence of leukoesterase
Leukoesterases are released by white blood cells as a response to an infection or inflammation. Therefore, the presence of this chemical in urine indicates a urinary tract infection. The presence of crystals in the urine indicates that the specimen had been allowed to stand. Presence of bilirubin in the urine indicates anorexia nervosa, diabetic ketoacidosis, and prolonged fasting. The presence of ketones indicates diabetic ketoacidosis.
1. A client develops acute glomerulonephritis after a recent streptococcal infection. The nurse should expect to find which clinical manifestation during the health history and physical examination? 1. Nocturia Correct 2. Periorbital edema 3. Increased appetite 4. Recent weight loss
Periorbital edema occurs because of the retention of fluid. The client will experience oliguria, not nocturia. The client will develop anorexia related to elevated toxic substances in the blood. The client will have a weight gain because of the retention of fluid.
Which drug prescribed to a client with a urinary tract infection (UTI) turns urine reddish-orange in color? 1. Amoxicillin 2. Ciprofloxacin 3. Nitrofurantoin Correct 4. Phenazopyridine
Phenazopyridine is a topical anesthetic that is used to treat pain or burning sensation associated with urination. It also imparts a characteristic orange or red color to urine. Amoxicillin is a penicillin form that could cause pseudomembranous colitis as a complication; it is not associated with reddish-orange colored urine. Ciprofloxacin is a quinolone antibiotic used for treating UTIs and can cause serious cardiac dysrhythmias and sunburns. It is not, however, responsible for reddish-orange colored urine. Nitrofurantoin is an antimicrobial medication prescribed for UTIs. This drug may affect the kidneys but is not associated with reddish-orange colored urine.
The nurse is caring for a client who has been diagnosed with glomerulonephritis. Which initial urinary finding supports this diagnosis? 1. Anuria 2. Dysuria 3. Polyuria Correct 4. Proteinuria
Protein in the urine (proteinuria) and hematuria (blood in the urine) are classic manifestations of the onset of glomerulonephritis because of the increased permeability of the vascular bed in the kidneys. Suppression of urine formation (anuria) is not an initial manifestation of glomerulonephritis; oliguria may be present. Pain or burning on urination (dysuria) is indicative of cystitis, not glomerulonephritis. Excessive urination (polyuria) does not occur as an initial change with glomerulonephritis; polyuria and nocturia may occur later with chronic glomerulonephritis, when the renal structures are destroyed.
A nurse is caring for a client with a diagnosis of cancer of the prostate. The nurse should teach the client that which serum level will be monitored throughout the course of the disease? 1. Albumin 2. Creatinine 3. Blood urea nitrogen (BUN) Correct 4. Prostate-specific antigen (PSA)
The PSA is an indication of cancer of the prostate; the higher the level, the greater the tumor burden. Albumin is a protein that is an indicator of nutritional and fluid status. Increased creatinine or BUN levels may be caused by impaired renal function as a result of blockage by an enlarged prostate but do not indicate that metastasis has occurred.
A client who has repeated episodes of cystitis is scheduled for a cystoscopy to determine the possibility of urinary tract abnormalities. The client asks the nurse to describe the procedure. Which is the nurse's most appropriate response? 1"It is a computerized scan that outlines the bladder and surrounding tissue." 2"It is an x-ray film of the abdomen, kidneys, ureters, and bladder after administration of dye." Correct3"It is the visualization of the inside of the bladder with an instrument connected to a source of light." 4"It is the visualization of the urinary tract through ureteral catheterization and the use of radiopaque material."
The response that the procedure is "The visualization of the inside of the bladder with an instrument connected to a source of light" answers the client's question and provides an accurate description of a cystoscopy. A cystoscopy is not a computerized examination. A cystoscopy does not involve x-ray films or dye. Radiopaque material is not used in a cystoscopy, and the catheter is inserted into the bladder via the urethra, not the ureters.
A nurse is caring for a client after surgical creation of a conduit diversion (ileal conduit). Which information will the nurse consider when planning care for this client? 1. Peristalsis is greatly decreased. 2. Stool continuously oozes from it. Correct 3. Urine continuously drains from it. 4. Absorption of nutrients is diminished.
The ureters are implanted in a segment of the ileum, and urine drains continually because there is no sphincter; continent catheterizable stomal reservoirs do not continually drain but are accessed with a catheter approximately every 4 hours. Ileal conduits are not neurologically innervated; therefore, no peristalsis exists. No feces are present in an ileal conduit. Absorption of nutrients is not affected by an ileal conduit.
A client complains of nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. On physical examination, the nurse finds a smooth, firm, and enlarged prostate. The digital rectal examination report indicates enlargement of prostate tissue surrounding the urethra. Which condition does the nurse suspect in the client? 1. Prostatitis 2. Paraphimosis 3. Prostate cancer Correct 4. Benign prostatic hyperplasia (BPH)
BPH is a benign enlargement of the prostate gland caused by excessive accumulation of dihydrotestosterone in the prostate cells, which can stimulate cell growth and overgrowth of prostate tissue surrounding the urethra. The clinical manifestations of BPH include nocturia, bladder pain, urinary frequency, urgency, and dribbling at the end of urination. Presence of fever, chills, back pain, and perineal pain, along with acute urinary symptoms such as dysuria, urinary frequency, urgency, and cloudy urine indicates prostatitis, which involves inflammation of the prostate gland. Tightness of the foreskin of the penis resulting in the inability to pull it forward from a retracted position and preventing normal return over the glans indicates paraphimosis. Symptoms of prostate cancer include dysuria, hesitancy, urinary urgency, and leaking or dribbling.
After a transurethral prostatectomy, a client returns to the postanesthesia care unit with a three-way indwelling catheter with continuous bladder irrigation. Which nursing action is the priority? 1. Observing the suprapubic dressing for drainage 2. Maintaining the client in the semi-Fowler position Correct 3. Monitoring for bright red blood in the drainage bag 4. Encouraging fluids by mouth as soon as the gag reflex returns
Blood clots are normal 24 to 36 hours after surgery, but bright red blood can indicate hemorrhage. The surgery is performed through the urinary meatus and urethra; there is no suprapubic incision. It is unnecessary to keep the client in the semi-Fowler position. The client is initially allowed nothing by mouth and then advanced to a regular diet as tolerated. Continuous irrigation supplies enough fluid to flush the bladder.
A nurse is providing preoperative teaching for a client who is scheduled for a transurethral resection of the prostate. To prepare the client what to expect postoperatively, which instructions should the nurse include in the teaching session? 1. The urine will be bright red for 24 to 48 hours. Correct 2. Spasms of the bladder occur during the first 24 to 48 hours. 3. To decrease bladder contractions, the Valsalva maneuver and Kegel exercises will be encouraged. 4. To maintain proper fluid balance, oral fluids are restricted during continuous urinary bladder irrigations.
Spasms are a common result postoperatively as a result from irritation of the bladder during surgery. However, it is important to let the client know that the spasms typically decrease in intensity and frequency as healing occurs. Bright red urine for 24 to 48 hours should be reported. This indicates hemorrhage which requires immediate intervention. Drainage should be dark red at first and after the first few hours gradually turn pink. The Valsalva maneuver should be avoided because it may initiate prostatic bleeding, not decrease bladder contractions. The presence of continuous bladder irrigation (CBI) is unrelated to the amount of oral fluids that should be consumed; once the CBI is discontinued, oral fluids should be encouraged.
Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response by the nurse is most appropriate? 1 "Your urine will be pink and free of clots." 2 "You will have an abdominal incision and a dressing." 3 "There will be an incision between your scrotum and rectum." Correct 4 "There will be an indwelling urinary catheter and a continuous bladder irrigation in place."
The presence of an indwelling urinary catheter and a continuous bladder irrigation are routine postoperative expectations after a TURP; they provide for hemostasis and urinary excretion. An abdominal incision and dressing are present with a suprapubic, not transurethral, prostatectomy. After a TURP, the client initially can expect hematuria and some blood clots; the continuous bladder irrigation keeps the bladder free of clots and the catheter patent. An incision between the scrotum and rectum is associated with a perineal prostatectomy, not a TURP.
The nurse is caring for a client 4 days after the client had a cystectomy and formation of an ileal conduit. After observing mucous threads in the client's urine, what should the nurse do? Correct 1. Recognize that this is an expected response. 2. Obtain a specimen for culture and sensitivity. 3. Report this to the primary healthcare provider immediately. 4. Increase the client's fluid intake for the next 12 hours.
This response is expected after a diversion because mucos is secreted continually by the intestinal mucosa. Reporting this to the primary healthcare provider immediately is not necessary; mucos is expected with an ileal conduit. Obtaining a specimen for culture and sensitivity is not necessary. At this point postsurgically the mucus is not an indication of infection. Although fluids should be encouraged to maintain urine flow, increasing the client's fluid intake for the next 12 hours will not eliminate mucus, which is discharged continually from the intestinal segment.