Foundations Chapter 36 Urinary Elimination

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen? -"Begin the collection when you first urinate in the morning." -"Discard your first urine and begin the collection after that." -"Start collecting the urine with the next time you urinate." -"You will need to have a catheter inserted for this collection."

-"Discard your first urine and begin the collection after that."

What accurately describes a guideline when inserting an indwelling catheter? -Use clean technique when inserting a catheter. -Maintain an open system whenever possible. -Use the largest appropriate-sized catheter. -Avoid irrigation unless needed to relieve an obstruction.

-Avoid irrigation unless needed to relieve an obstruction.

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? -Pale yellow -Colorless -Dark amber -Tea colored

-Dark amber 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.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this? -Having the client sign a consent form for the procedure -Explaining to the client that the procedure will be painful -Maintaining the client without liquids before the procedure -Inserting a Foley catheter the morning of the procedure

-Having the client sign a consent form for the procedure

Two nurses, an RN and a wound care nurse, are discussing care of a client's wound that has nonviable tissue in the base. The wound care nurse recommends that the RN utilize a dressing that would promote autolytic debridement of the wound. Which dressing should the nurse select? -Hydrocolloid -Wet to dry -Negative wound pressure therapy -Telfa

-Hydrocolloid

Which term describes obstruction within the urinary system leading to distention of the renal pelvis? -Pyuria -Hematuria -Hydronephrosis -Ureteritis

-Hydronephrosis One of the complications of obstruction within the urinary system is hydronephrosis, which is distention of the kidney pelvis with urine secondary to the increased resistance caused by obstruction to normal urine flow. Pyuria refers to the presence of pus in the urine. This manifestation is associated with an infection. Hematuria is the presence of blood in the urine. Ureteritis is the inflammation of a ureter.

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this client? -Impaired Skin Integrity related to functional incontinence -Urinary Incontinence related to urinary tract infection -Impaired Skin Integrity related to urinary bladder infection and dehydration -Risk for Urinary Tract Infection related to dehydration

-Impaired Skin Integrity related to urinary bladder infection and dehydration

A nurse notes that the volume of the client's urinary elimination is less than 50 mL/day. What could be the possible cause for the low volume of urination by the client? -Diuretic medication -Endocrine disease -Kidney dysfunction -Liver disease

-Kidney dysfunction

The client is preparing to obtain a clean-catch midstream urine specimen. List in order the steps needed to complete the diagnostic test. -Void a small amount into stool. -Clean the area surrounding the urinary meatus with the provided cloth. -Submit collected specimen to the health care professional. -Void into the provided collection device. -Provide instruction to the client. -Secure the lid on the specimen container.

-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.

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

-Purge air from the tubing. When providing continuous bladder 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. The urinary meatus is cleaned when removing the catheter, not during continuous bladder irrigation.

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? -Delegate catheter discontinuation to the unlicensed assistive personnel (UAP). -Discontinue the catheter and document in the electronic health record. -Request an order for catheter discontinuation from the health care provider. -Maintain the drainage bag above the bladder when the client ambulates.

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

A nurse is caring for a client at a wound care clinic. The client has a 5-cm × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? -Primary intention -Secondary intention -Tertiary intention -Desiccation

-Secondary intention

The nurse is preparing to insert an IV for a client with dehydration. Which dressing supply will the nurse gather to take in the client's room? -gauze -Montgomery straps -Tegaderm -DuoDerm

-Tegaderm

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. -A neurogenic bladder results from local anesthesia. -A urinary tract infection results from the birth process. -Catheterization is necessary for 1 week.

-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 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 asks the client to take a deep breath when resistance was met during insertion of the catheter. -The novice nurse selects an 18 French Foley catheter to insert. -The novice nurse places a trash receptacle within easy reach. -The novice nurse assists the client to a dorsal recumbent position with knees flexed, feet about 2 ft (0.6 m) apart

-The novice nurse selects an 18 French Foley catheter to insert. A 14F to 16F catheter should be used when catheterizing an adult client. Size 18F can distend the urethra and cause more discomfort to the client during the procedure, as well as increase erosion of the bladder. If resistance is met, having the client take a deep breath helps relaxes the external sphincter. Placing a trash receptacle within easy reach trash allows for prompt disposal of used supplies and reduces the risk of contaminating the sterile field. The dorsal recumbent position allows adequate visualization of the urinary meatus.

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

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

A student nurse is preparing to perform a dressing change for a pressure ulcer on a client's sacrum area. The chart states that the pressure ulcer is staged as "unstageable." Which wound description should the student nurse expect to assess? -The wound is 3 cm × 5 cm with yellow tissue covering the entire wound. -The wound is 3 cm × 5 cm with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. -The wound is 3 cm × 5 cm with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing. -The wound is a 3 cm × 5 cm blood-filled blister.

-The wound is 3 cm × 5 cm with yellow tissue covering the entire wound.

The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include? -Tighten the internal muscles used to prevent or interrupt urination. -Keep muscles contracted for at least 30 seconds. -Relax muscles for at least 1 minute between Kegels. -Perform these exercises 10 times daily for 1 month.

-Tighten the internal muscles used to prevent or interrupt urination. Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen three to four times daily for 2 weeks to 1 month.

Which type of wound drainage should alert the nurse to the possibility of infection? -foul-smelling drainage that is grayish in color -copious wound drainage that is blood-tinged -large amounts of drainage that is clear and watery -drainage that appears to be mostly fresh blood

-foul-smelling drainage that is grayish in color

What is the best nursing diagnosis to describe a minor laceration to finger sustained when a client was cutting fruit in the kitchen with a knife? -impaired skin integrity related to open wound -pain related to wound sustained by knife -knowledge deficit regarding wound care related to laceration -risk for infection related to wound

-impaired skin integrity related to open wound

Overflow incontinence

associated with overdistention and overflow of the bladder, whereby the signal to empty the bladder is lost, the bladder fills, and the client dribbles urine.

Total incontinence

may be the result of surgery, trauma, or physical malformation; the client has continuous and unpredictable loss of urine.

Functional incontinence

occurs because the client is unable to reach the toilet.

Stress incontinence

related to an increase in intra-abdominal pressure and commonly occurs during activities such as coughing and sneezing.

24-hour urine specimen

required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day.

clean-catch or midstream-voided specimen

used when a specimen relatively free from microorganisms is required.

Random urine specimen

used when sterile urine is not required.

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? -"I should keep this on my ankle until it is numb." -"I must wait 15 minutes between applications of cold therapy." -"I will put a layer of cloth between my skin and the ice pack." -"I can let this stay on my ankle an hour at a time."

-"I will put a layer of cloth between my skin and the ice pack."

The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse? -"I will place a bath blanket over the client to provide privacy." -"The client will be placed in a reclining position with knees bent." -"I will use clean gloves to handle the catheter and other equipment." -"Washing hands before and after the procedure is important."

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

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? -"It would be best just to get some adult diapers." -"Let me refer you to a urologist who can help you." -"Don't worry, this is a normal condition for older adults." -"Let's explore structuring activities and toileting breaks."

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

The nurse is caring for a client for whom maggot therapy has been ordered for a nonhealing leg wound. The client states, "You're not putting those nasty bugs on me!" What is the appropriate nursing response? Select all that apply. -"We have to do this treatment to help your wound heal." -"Medical maggots are sterilized before they are introduced to the wound." -"I understand your concern; let's talk further about your thoughts about this treatment." -"If you do not have this debridement, you will get septicemia and possibly die." -"The choice regarding whether to have or decline this treatment is yours."

-"Medical maggots are sterilized before they are introduced to the wound." -"I understand your concern; let's talk further about your thoughts about this treatment." -"The choice regarding whether to have or decline this treatment is yours."

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."

The nurse is applying a saline-moistened dressing to a client's wound. The client asks, "Wouldn't it be better to let my wound dry out so a scab can form?" Which response is most appropriate? -"Wounds heal better when a moist wound bed is maintained." -"This wound is too large for a scab to form over it, so a moist dressing is the best alternative." -"You may be correct. I will check with your primary health care provider." -"Allowing a scab to form would prevent us from observing the wound for signs of infection."

-"Wounds heal better when a moist wound bed is maintained."

An older adult client has come to the emergency room stating, "I have not been able to urinate for 24 hours. Which statement made by the client is an indicator for the inability to void? -"I had a urinary tract infection about a year ago," -"I drink eight glasses of water per day". -"Yesterday I was congested so I took several doses of Benadryl." -"I take stool softener each day so I have regular bowel movements."

-"Yesterday I was congested so I took several doses of Benadryl."

Which range for urine output in 24 hours is considered normal for an adult? -1,000-1,200 mL -1,200-1,500 mL -1,600-1,900 mL -2,000-2,400 mL

-1,200-1,500 mL

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 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? -High fever -Dysuria -Acute confusion -Nausea

-Acute confusion Symptoms of UTI are different in the older adult, especially if the immune system is depressed. Rather than experiencing painful urination and a high fever, the older adult will become acutely confused.

An obese client on the unit has demonstrated difficulty healing a large pressure ulcer. The nurse correctly recognizes that this is most likely because of which factor? -The client's size limits his activity level. -Adipose tissue is poorly vascularized. -Obesity is linked to impaired white blood cell function. -The amount of tissue needing healing will increase the amount of time needed to adequately heal the wound.

-Adipose tissue is poorly vascularized. Wound healing may be decreased in obese clients. Because adipose tissue is relatively avascular, it provides only a weak defense against microbial invasion and impairs delivery of nutrients to the wound.

A nurse is evaluating a client's laboratory data. Which laboratory findings should the nurse recognize as increasing a client's risk for pressure ulcer development? -Hemoglobin A1C 5% -Blood urea nitrogen (BUN) 7 mg/dL (2.50 mmol/L) -Albumin 2.8 mg/dL (28.0 g/L) -White blood cell count 14,800 mm3 (14.8 x 109/L)

-Albumin 2.8 mg/dL (28.0 g/L)

A nurse is caring for a client who has a 6-cm × 8-cm wound caused by a motor vehicle accident. The wound is currently infected and draining large amounts of green exudate. A foul odor is also noted. The wound bed is moist with a yellow and red wound bed. Which dressing does the nurse anticipate is best to be ordered by the primary care provider? -Alginate -Hydrogel -Hydrocolloid -Transparent

-Alginate Alginates are used in infected or noninfected wounds with moderate to heavy drainage. Alginates are used with moist wound beds with red and yellow tissue. Hydrogels are used with dry wounds or wounds with minimal drainage. Hydrocolloids are used with light to moderate drainage in wounds with necrosis or slough. Transparent dressings are used with wounds having minimal drainage, small size, and partial thickness.

Which scenario does not illustrate a normal lifespan variant regarding urination? -An 8-year-old is continent during the day but is incontinent 2 times during the night. -A toddler age 3 1/2 is showing interest in being ready for toilet training by showing that he can undress himself and by being able to stay dry for 2 hours at a time. -The urine of a neonate, 5 hours old, appears pink-tinged. -A 10-year-old child has been voiding straw-colored urine 6 or 7 times a day.

-An 8-year-old is continent during the day but is incontinent 2 times during the night.

A nurse is assessing a client who is complaining of difficulty urinating. Which assessment would be a priority? -Asking the client when he or she had last urinated -Determining any pain when palpating the lower abdomen -Palpating the bladder above the symphysis pubis -Obtaining the bladder scanner to check the urine volume

-Asking the client when he or she had last urinated In assessing the bladder, the nurse would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.

A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which nursing action should be included? -Encourage the client to wait to at least 30 minutes before voiding when the urge is felt. -Place the client on a schedule to void every 4 hours during the daytime hours. -Assist the client to a normal voiding position when possible. -Explain to the client that privacy is not important with urination.

-Assist the client to a normal voiding position when possible.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? -Autolytic debridement -Biosurgical debridement -Enzymatic debridement -Mechanical debridement

-Biosurgical debridement

A nurse is caring for a client who has a pressure ulcer on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? -Red classification -Yellow classification -Black classification -Unstageable

-Black classification

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. 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 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.

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action? -Check health record for provider's order. -Gather equipment and supplies. -Assess urine characteristics. -Explain the procedure to the client.

-Check health record for provider's order. The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after the order is confirmed.

A client could experience increased urination when using which classification of medication? -Cholinergic agents -Analgesic medications -Central nervous system depressants -Stool softeners

-Cholinergic agents Cholinergic agents stimulate the detrusor muscle, which causes more frequent urination.

A nurse is caring for a client with a chronic wound on the left buttock. The wound is 8.3 cm x 6.4 cm. Which action should the nurse use during wound care? -Cleanse the wound from the outer area towards the inner area. -Cleanse at least 0.5 inch (1.25 cm) beyond the end of the new dressing. -Cleanse the wound using parallel stroke from the top to the bottom of the wound. -Cleanse with a new gauze for each stroke.

-Cleanse with a new gauze for each stroke.

To promote drainage of a client's Foley catheter, which intervention would be most important for the nurse to implement? -Keeping the catheter drainage bag off the floor at all times -Ensuring the balloon on the catheter is properly inflated with insertion -Securing the catheter to the client's thigh or abdomen after placement -Confirming the catheter tubing is not laying under the client

-Confirming the catheter tubing is not laying 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. -Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). -Perform, or allow client to perform, perineal hygiene at least once daily. -Ensure that the drainage bag is above the level of the bladder at all times. -Discontinue to catheter and report this to the healthcare provider.

-Contact the health care provider to ask for an order for catheter discontinuation. -Perform, or allow client to perform, perineal hygiene at least once daily.

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. -Cover wound with a gauze moistened with normal saline. -Reinsert protruding structures and apply a pressure dressing. -Place client in low-Fowler's position. -Use sterile techniques. -Pack the wound with iodoform gauze.

-Cover wound with a gauze moistened with normal saline. -Place client in low-Fowler's position. -Use sterile techniques.

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 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. -Increase IV fluids to compensate. -Contact the healthcare provider to decrease furosemide. -Administer additional as needed (prn) dose of furosemide.

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

The nurse is caring for a client with urinary incontinence who has a prescription for a postvoid residual (PVR) collection. A catheter is inserted, and 45 mL of amber urine is returned via PVR. Which appropriate action would the nurse take with this data collection? -Encourage the client to drink more fluids. -Wait 30 minutes and recatheterize the client. -Document the finding. -Perform a bladder scan.

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

A 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. -Wipe the perineal area from the rectal area to the urethra. -Take baths instead of showers. -Wear satin or silk underwear that hugs the skin tightly.

-Drink two glasses of water before and after sexual intercourse. 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. Drinking two glasses of water encourages urination before and after sexual intercourse which can cleanse the urethra of any bacteria caused by the intercourse.

When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply. -Use powder or lotion in the perineal area. -Encourage fluid intake, unless contraindicated. -Record volume and character of the urine. -Maintain a closed urinary catheter system. -Change the indwelling catheter regularly.

-Encourage fluid intake, unless contraindicated. -Record volume and character of the urine. -Maintain a closed urinary catheter system.

A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence? -Stress -Urge -Functional -Total

-Functional

A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours? -Functional incontinence -Transient incontinence -Stress incontinence -Reflex incontinence

-Functional incontinence

Which urinary care teaching will the nurse provide to a young adult female client? -Wipe from the back to the front. -Refrain from douching unless ordered by a health care provider. -If you do not feel like voiding, still strain to make sure the bladder is empty. -Drink water more frequently in the morning and evening to facilitate hydration.

-Refrain from douching unless ordered by a health care provider.

Which urinary care teaching will the nurse provide to a young adult female client? -Wipe from the back to the front. -Refrain from douching unless ordered by a health care provider. -If you do not feel like voiding, still strain to make sure the bladder is empty. -Drink water more frequently in the morning and evening to facilitate hydration.

-Refrain from douching unless ordered by a health care provider. Douching is not recommended unless ordered by the health care provider. Female clients should be taught to wipe from the urinary area towards the rectum to decrease the risk for introducing pathogens into the urethra. Straining is not appropriate. Water should be consumed throughout the day, not just in the morning and evening.

The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions? -The client drinks eight 8-oz glasses of cranberry juice daily. -The client soaks in the bathtub daily for perineal care. -Since the client is symptom-free, she no longer takes the prescribed antibiotics. -The client drinks two glasses of water before and after sexual intercourse.

-The client drinks two glasses of water before and after sexual intercourse.

The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted? -The novice nurse measures the height of the edge of the bladder above the symphysis pubis. -The novice nurse asks the client when was the last time he voided before palpating the bladder. -The novice nurse observes the lower abdominal wall for any swelling. -The novice nurse asks the client to urinate before palpating the bladder.

-The novice nurse asks the client to urinate before palpating the bladder.

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

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? -Blood urea nitrogen (BUN) - 7 mg/dL (19.6 mmol/L) -Urine culture sensitivity - 100,000/mL -Hemoglobin - 40% (0.40) -Magnesium - 2.5 mEq/L (2.5 mmol/L)

-Urine culture sensitivity - 100,000/mL 100,000 organisms per milliliter in a urine culture and sensitivity specimen is positive of a urinary tract infection. BUN, hemoglobin, and magnesium are all within the normal ranges.

The nurse is assessing the wounds of clients. Which clients would the nurse place at risk for delayed wound healing? Select all that apply. -an older adult who is confined to bed -a client with a peripheral vascular disorder -a client who is obese -a client who eats a diet high in vitamins A and C -client who is taking corticosteroid drugs -a 10-year-old client with a surgical incision

-an older adult who is confined to bed -a client with a peripheral vascular disorder -a client who is obese -client who is taking corticosteroid drugs

A client's hand was severely wounded upon coming in contact with a running lawn mower blade. The nurse notes that large amounts of flesh are missing, and the bones of two fingers are visible. How will the nurse document this assessment finding? -puncture -laceration -contusion -avulsion

-avulsion An avulsion involves stripping away of large parts of tissue leaving cartilage and bone exposed. Therefore, the nurse will document this assessment finding as an avulsion. A puncture involves an opening of skin caused by a narrow, sharp, pointed object. A laceration involves separation of skin and tissue with torn, irregular edges. A contusion is an injury to soft tissue. Therefore, the nurse would not document the finding as a puncture, laceration, or contusion.

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should: -deflate the balloon, insert the catheter further, and slowly attempt reinflation. -wait for 30 seconds, help the client to relax, and attempt inflation again. -Stop, deflate the balloon, withdraw the catheter 2 to 4 cm, and slowly reinflate. -Deflate the balloon, withdraw the catheter, and use a smaller sized catheter.

-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 -hypovolemia -balanced fluids -renal failure

-dehydration

Which best describes the third phase of the wound healing process: proliferative? -the onset of vasoconstriction, platelet aggregation, and clot formation -marked by vasodilation and phagocytosis as the body works to clean the wound -epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization -the number of fibroblasts decreases, collagen synthesis is stabilized and collagen fibrils become increasingly organized, resulting in greater tensile strength of the wound

-epidermal cells, which appear pink, reproduce and migrate across the surface of the wound in a process called epithelialization In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. The onset of vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing—hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibril become increasingly organized.

The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing: -oliguria -anuria -nocturia -polyuria

-oliguria Oliguria is a significant decrease in urine production. Anuria is an absence or near-absence of urine output. Nocturia is nighttime awakening to void. Polyuria is greatly increased urine production.

A nurse is the guest speaker at a women's club. Most of the women are over the age of 40 years. The women have asked the nurse to speak on health promotion topics. In the area of urinary urgency, the nurse will instruct the women to: -limit fluid intake. -increase caffeine daily. -take an antispasmodic. -perform Kegel exercises.

-perform Kegel exercises. Pelvic floor exercises or Kegel exercises strengthen the pubococcygeal muscles and effectively promote urinary control.

A nurse is caring for a client with laceration wounds on the knee. The nurse notes that the client is in remodeling phase of wound repair. Which statement describes this phase of wound recovery? -physiologic defense immediately after the tissue injury -period during which new cells fill and seal a wound -process by which damaged cells recover and reestablish normal function -period during which the wound undergoes changes and maturation

-period during which the wound undergoes changes and maturation

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: -protein. -calculi. -pus. -casts.

-pus.

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? -cloudy, foul odor -light yellow, clear -clear, colorless -strongly aromatic, dark amber

-strongly aromatic, dark amber The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.