Fundamental Chapter 38 Urinary Elimination

During data collection, the client expresses concern over a change in the color of the urine from tea-colored to green since beginning a new medication. Which appropriate question would the nurse ask this client? "Are you taking a diuretic?" "Are you taking any B-complex vitamins?" "Are you taking phenazopyridine?" "Are you taking levodopa?"

"Are you taking any B-complex vitamins?"

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."

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

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

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.

The nurse is caring for a client who has a history of acute kidney injury. What is an accurate step when caring for the client's hemodialysis access? Percuss the site to feel for a thrill or vibration. Auscultate over the site with a stethoscope to listen for a bruit. Use the affected arm if an IV must be started to avoid impairment of both arms. If a thrill is not palpable and/or a bruit is not detectable, assess for these signs in the other arm.

Auscultate over the site with a stethoscope to listen for a bruit.

What accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter? Use clean technique when inserting a catheter. Maintain an open system whenever possible. Use the largest appropriate-sized catheter in order to prevent leakage. Avoid irrigation unless needed to relieve an obstruction.

Avoid irrigation unless needed to relieve an obstruction.

Which statement should the nurse convey to the parent of a 3-year-old boy 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 teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen? Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet. Catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs. Catch the urine while holding the labia apart, after cleansing. Fill the specimen cup. Catch the urine in the cup after cleansing the perineum.

Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.

A client admitted to the hospital with chronic kidney injury suddenly develops the following signs and symptoms: left arm arteriovenous (AV) fistula has weak thrill and bruit; blood pressure 88/40 mm Hg; states feeling dizzy. Which action will the nurse implement first? Notify the primary health care provider. Change to supine position. Instruct to not get out of bed. Examine that clothing is not constrictive on arm.

Change to supine position.

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.

Urinalysis and urine culture testing have been ordered for a client who has an indwelling urinary catheter. The nurse observes that there is currently no urine in the client's catheter tube. What should the nurse do? Encourage the client to increase fluid intake for the next couple of hours. Clamp the tube below to access the port to allow urine to accumulate. Reposition the client supine. Attach a syringe to the access port and aspirate until a sample is obtained.

Clamp the tube below to access the port to allow urine to accumulate.

A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first? Release a small amount of urine into the toilet. Void normally to empty the bladder. Clean each side of the urinary meatus with a separate wipe. Catch a sample of urine in the specimen container.

Clean each side of the urinary meatus with a separate wipe.

A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? Select all that apply. Diminished ability of kidneys to concentrate urine may result in nocturia. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. Decreased bladder contractility may lead to urine retention and stasis. Neuromuscular problems may interfere with voluntary control of urination. Increased bladder motility decreases the incidence of urinary tract infections. Altered thought processes may cause urinary frequency.

Diminished ability of kidneys to concentrate urine may result in nocturia. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. Decreased bladder contractility may lead to urine retention and stasis. Neuromuscular problems may interfere with voluntary control of urination. Altered thought processes may cause urinary frequency.

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 is prescribed an indwelling urinary catheter for 2 days prior to surgery. Which action should the nurse take to decrease the occurrence of health care-associated infection (HAI) for this client? Encourage fluid intake. Maintain the urinary catheter until discharge. Request a straight catheter from the health care provider. Irrigate the catheter twice per day.

Encourage fluid intake.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next? Have the client drink 8 ounces of water every 15 minutes for 1 hour. Wipe off some of the ultrasound gel and rescan. Ensure proper positioning of the scanner head and rescan. Place the client on either side and rescan.

Ensure proper positioning of the scanner head and rescan.

The nurse has placed a urine collection bag on an infant. How often should the nurse check the bag to see if the infant has voided? Every 15 minutes Every 30 minutes Every 45 minutes Every 60 minutes

Every 15 minutes

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? Remove the catheter every 8 hours, or more often in humid weather. Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application. Fasten the condom securely enough to prevent leakage without constricting blood flow. Ensure the tip of the tubing is touching the tip of the client's penis.

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

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. Measure the height of the edge of the bladder below the symphysis pubis. Inspect the urethral orifice for any signs of inflammation, discharge, or foul odor. Place male clients in the dorsal recumbent position for good visualization of the meatus. 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.

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 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 an indwelling urethral catheter Insertion of a suprapubic catheter Insertion of a straight catheter Insertion of a urologic stent

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 urinary retention. It causes urine to turn blue-green. It decreases sensation of bladder fullness. It decreases glomerular filtrate rate.

It causes urine to turn blue-green.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle (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 repetitions. 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 caring for a female client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action? Many clients find it embarrassing or degrading to use a bedpan. Incorrect placement of a bedpan has been linked to development of UTIs. Bedpans should not be used if the client needs to defecate. The bed should be lowered to the lowest height before placing the bedpan.

Many clients find it embarrassing or degrading to use a bedpan.

A nurse is maintaining a client's continuous bladder irrigation. When appraising the effectiveness of this therapy, the nurse should prioritize what assessment? Calculating the flow rate of urinary output Monitoring the characteristics of the urinary output Assessing PVR using a bladder scanner Palpating the client's bladder region

Monitoring the characteristics of the urinary output

During the well-child checkup for 2-year-old twins (one boy, one girl), their parent asks the nurse about preparing to toilet train the children. What information can be provided to the parent? Select all that apply. It is typically more difficult to toilet train a female child. Nighttime continence will occur in some children after age 4 or 5 years. Daytime incontinence is not a concern while toilet training. Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training. Children old enough to undress themselves will have increased abilities to toilet train.

Nighttime continence will occur in some children after age 4 or 5 years. Daytime incontinence is not a concern while toilet training. Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training. Children old enough to undress themselves will have increased abilities to toilet train.

The nurse assesses redness, drainage, and odor to the area around a client's peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? Flushing the catheter with 15 - 20 mL of normal saline Obtaining laboratory studies. Sitting the client up in a greater than a 40-degree angle. Notifying the health care provider of the assessment findings.

Notifying the health care provider of the assessment findings.

A nurse is collecting a routine urinalysis on a client presenting to the emergency room with abdominal pain. What nursing action is important in the collection of this specimen? Obtain a nonsterile specimen and send it to the lab. Obtain a sterile specimen and send it to the lab. Obtain a sterile specimen and allow it to settle at room temperature for 2 hours. Obtain a nonsterile specimen, allow it to settle at room temperature for 2 hours, and then send it to the lab.

Obtain a nonsterile specimen and send it to the lab.

The nurse is caring for a postoperative client just returning from surgical insertion of a peritoneal dialysis catheter. Which are the nurse's priority assessments of the peritoneal dialysis catheter insertion site? Select all that apply. Odor Bleeding Drainage Urine output Pain

Odor Bleeding Drainage Pain

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. Reposition the client in high-Fowler's position. Check to make sure that the tubing is not kinked. If return flow remains decreased, notify the health care provider. Deflate and then reinflate the catheter balloon. Remove the catheter.

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

The nurse is caring for an older adult client who has had a condom catheter applied. Which intervention will the nurse include in the care of this client? Perform thorough skin care daily. Change the condom catheter every other day. Make sure the condom sheath is secured tightly to the penis. Ensure the tubing is flush to the tip of the penis.

Perform thorough skin care daily.

A nurse will use a bladder scanner to assess a client with urinary frequency. How should the nurse best prepare the client for this procedure? Position the client in a supine position. Administer a diuretic, as ordered. Have the client rest for 15 minutes before the assessment. Assess the client's need for analgesia.

Position the client in a supine position.

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? Place the sterile solution on the bed. Prime the tubing with the solution. Empty the balloon with a syringe. Clean around the urinary meatus.

Prime the tubing with the solution.

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.

A nurse is administering continuous closed bladder irrigation to a client. After performing this intervention, the nurse observes that the irrigation solution is not flowing at the prescribed rate. Which actions should the nurse take? Select all that apply. Raise the bag 3 to 6 in (7.5 to 15 cm). Check the tubing for kinks or pressure points. Open the clamp all the way. Have the client stand, so that gravity can assist the irrigation process. Increase the speed at which the plunger in the syringe is being pushed. Encourage the client to drink a glass of water.

Raise the bag 3 to 6 in (7.5 to 15 cm). Check the tubing for kinks or pressure points. Open the clamp all the way.

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.

A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client? Encouraging the client to stay close to home Fluid restriction Indwelling catheterization Regular toileting routine

Regular toileting routine

x 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 completes the task of changing the dressing of a recent surgically inserted peritoneal dialysis catheter. The nurse has applied antibiotic ointment as prescribed, covered the site with 4 × 4 gauze, and labeled the dressing with the date, time of change, and initials of the nurse performing the task. Prior to leaving the client's bedside, the nurse should complete which task next? Secure the tubing of the peritoneal dialysis catheter to the client's abdomen. Replace the linens under the client to decrease moisture. Perform hand hygiene. Ensure that the client's bed is in a locked position.

Secure the tubing of the peritoneal dialysis catheter to the client's abdomen.

The nurse is engaged in collecting a urine specimen for a routine urinalysis from a client with an indwelling catheter. What nursing action has the greatest impact on the accuracy of the testing results? Using a syringe that holds at least 10 ml Selecting this particular specimen port site Wearing gloves for the procedure Positioning the client as shown

Selecting this particular specimen port site

x The health care provider requests an indwelling urinary catheter to be inserted into a woman who has had a total hip replacement and is on strict bed rest. When inserting the catheter, the nurse would place the client in which position? Dorsal recumbent Sims Supine Semi-Fowler

Sims

The nurse is caring for a client who has been experiencing difficulty voiding in the 8 hours since giving birth vaginally. 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 can result from the birth process. Catheterization is likely necessary for 5 to 7 days.

The birth can cause perineal swelling.

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 external opening to the urethra should always be sterilized. Pathogens introduced into the bladder remain in the bladder. A normal bladder is as susceptible to infection as an injured one.

The bladder normally is a sterile cavity.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal? The client was treated for kidney stones a few months earlier. The client has a history of benign prostatic hyperplasia (BPH; prostate enlargement). The client has had urinary catheters in place repeatedly during previous admissions. The client is acutely confused and has been diagnosed with delirium.

The client is acutely confused and has been diagnosed with delirium.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions? The client may bathe rather than shower, provided the site is covered with gauze. A dressing should always be worn over the site to avoid leaking. Sterile technique must be observed by the client in the home setting. The client should avoid wearing tight clothes or belts near the site.

The client should avoid wearing tight clothes or belts near the site.

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? This urinary diversion is only temporary. The client will need to change the urinary pouch every 4 hours. The client will have to wear an external appliance to collect urine. Urination can be voluntarily controlled after the stoma heals from the initial surgery.

The client will have to wear an external appliance to collect urine.

A nurse uses a portable bladder ultrasound device to assess bladder volume for a client who is unable to void. Which statement accurately details information needed to interpret the results? The scan is contraindicated for female clients who have had a hysterectomy. The device must be programmed for the biological sex of the client by pushing the correct button on the device. Three separate readings should be obtained over 1 hour and the postvoid residual (PVR) averaged. A PVR of 450 mL is often recommended as the guideline for catheterization.

The device must be programmed for the biological sex of the client by pushing the correct button on the device.

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. A regular bedpan is generally more comfortable for clients than a fracture bedpan. A fracture bedpan 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 largest part of a regular bedpan should be placed under the client's buttocks.

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. TAKE ANOTHER QUIZ

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.

The nurse has received an order to remove a client's indwelling urinary catheter. Which actions are appropriate when carrying out this order? Select all that apply. The nurse may delegate this task to unlicensed assistive personnel (UAP). Strict aseptic technique must be used when removing the client's catheter. The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe. Limit the client's fluid intake for 2 to 4 hours prior to removal.

The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe.

The nurse is assessing a client with an older arteriovenous (AV) graft for hemodialysis access in the left arm. The client reports significant pain to the distal left arm. Capillary refill in the left hand is greater than 4 seconds. Which should the nurse assess before contacting the health care provider? Respiratory rate Temperature Thrill and bruit Pedal pulses

Thrill and bruit

The nurse is teaching a client how to perform pelvic floor muscle (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 contractions. Perform these exercises 10 times daily for 1 month.

Tighten the internal muscles used to prevent or interrupt urination.

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

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. If nocturnal incontinence is anticipated, a urinal can be placed between the legs while the client is asleep. Urinals must be replaced every 24 hours to reduce the risk of infection. Both male and female clients commonly void into a urinal in the bathroom to facilitate measurement of urinary output.

Unless contraindicated, nurses should encourage clients to stand to use a urinal.

The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice? Specimen hat Large urine collection bag Bedpan Urinal

Urinal

The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed? Blood urea nitrogen (BUN) - 7 mg/dL (19.6 mmol/L) Urine culture sensitivity - 100,000/mL Hemoglobin - 16 g/dL Magnesium - 2.5 mEq/L (2.5 mmol/L)

Urine culture sensitivity - 100,000/mL

A nurse is inserting a catheter into a female urinary bladder. Which nursing action is performed correctly? Clean the perineal area with a gauze pad and alcohol using a different corner of the gauze with each stroke. Assist the client to a prone position with knees flexed, feet about 2 ft (0.6 m) apart, with legs abducted. Using dominant hand, hold the catheter 1 ft (0.3 m) from the tip and insert slowly into the urethra. Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.

Use dominant hand to inflate the catheter balloon, and inject entire volume of sterile water supplied in prefilled syringe.

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 pr

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.

A sterile urine specimen for culture and sensitivity has been prescribed 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 aseptic technique. 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 aseptic technique.

A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample? a sample of fresh urine collected in a clean container a sample of urine collected in a sterile environment a sample of urine collected over a period of 24 hours a sample of urine that is considered sterile

a sample of urine that is considered sterile

A male client is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. The client's skin is also excoriated from urinary incontinence. Which nursing concern is most appropriate for the nurse to include in this client's car plan? altered skin integrity related to functional incontinence urinary incontinence related to urinary tract infection altered skin integrity related to urinary bladder infection and dehydration urinary tract infection risk related to dehydration

altered skin integrity related to urinary bladder infection and dehydration

A client with a new urostomy requires teaching by the nurse. The nurse will construct the plan of care and education based upon which nursing concern(s)? Select all that apply. altered skin integrity risk stress urinary incontinence infection risk situational low self-esteem functional urinary incontinence

altered skin integrity risk infection risk situational low self-esteem

The client is a new client in the outpatient wellness clinic. The client reports frequent urinary incontinence of recent onset. The nurse reviews the client's list of medications. Which medication classification will the nurse review with the client to determine when the prescription was started? antihypertensive nonsteroidal anti-inflammatory drug (NSAID) H2-receptor antagonist calcium supplement

antihypertensive

A nurse has received an order to insert a urinary catheter into a female client. In preparation, the nurse asks if she has ever had an indwelling catheter and, if so, why and for how long. The nurse has performed which action? assessed for the most appropriate size of catheter to insert assessed the possibility that the client has urethral strictures assessed the client's risk of hemorrhage during insertion gauged the client's risk of developing a urinary tract infection

assessed the possibility that the client has urethral strictures

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend? fracture pan bedside commode bed pan regular bathroom

bedside commode

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

For which client will the nurse plan interventions addressing a neurogenic bladder? client with weak pelvic floor muscles client being treated for pyelonephritis 4-year old child who has not successfully been toilet trained client recovering from a stroke

client recovering from a stroke

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 an older adult client suspected of having a urinary tract infection. The nurse will perform what assessment specifically associated with the development of this condition in the older adult? temperature assessment assessment for dysuria cognitive assessment assessment for nausea

cognitive assessment

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? condom catheter indwelling catheter intermittent catheterization at bedtime toileting the client every 2 hours

condom catheter

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 0.75 to 1.5 in (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 kidney injury

dehydration

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 preparing to place a Foley catheter for a female client who will soon have surgery. Into what position will the nurse place the client? supine dorsal recumbent lithotomy semi-Fowler's

dorsal recumbent

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

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? indwelling urethral catheter intermittent urethral catheter Foley catheter retention catheter

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.

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.

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 what? protein calculi pus casts

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: urge incontinence. stress incontinence. functional incontinence. reflex incontinence.

reflex incontinence.

The nurse is planning care for a client with a newly placed urostomy. For what priority problems will the nurse address and provide interventions? Select all that apply. urinary retention reflex urinary incontinence impaired urinary elimination situational low self-esteem risk for infection

situational low self-esteem risk for infection

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

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 suprapubic catheter is used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area.

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? urge reflect stress total

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? reflex incontinence stress incontinence urge incontinence functional incontinence

stress incontinence The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to giving birth. 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.

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 school nurse is caring for a student who experienced a seizure in the classroom. The student was noted to lose a large amount of urine during the seizure. Which type of incontinence does the nurse anticipate the client may have experienced? total urge reflex stress

total

A client has been diagnosed with an overactive detrusor muscle causing involuntary bladder contractions. When planning the client's care, the nurse will address what health problem? urge incontinence stress incontinence recurrent urinary tract infections pyelonephritis

urge incontinence