Fundamentals Chapter 37

The nurse has an order to obtain a urine specimen from a client with an indwelling Foley catheter. Which supplies would the nurse need to gather? Select all that apply. 10-mL (milliliter) syringe Sterile gloves Sterile specimen container Antiseptic swab Consent form

A,C,D

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

B

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.

B

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

B

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

D

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

True

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

A

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

A

A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? anuria oliguria nocturia urinary retention

A

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

A

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take? Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. Administer an IV on the arm high above the access site. Perform venipuncture below the access site to obtain a blood sample for laboratory testing. Measure the client's blood pressure on the arm above the access site.

A

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.

A

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.

A

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.

A

The nurse instructs the client about the clean catch urine specimen. Which statement made by the client indicates a need for further teaching from the nurse? "I will: urinate directly into the specimen cup, filling it to the top and then cap it without touching the inside of the lid." use three wipes provided; one to clean each side of the urinary meatus, and one in the middle from front to back." wash my hands before collecting the clean catch urine specimen." keep the labia spread after cleaning and during collection of the specimen."

A

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

A

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

A

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? The client has an enlarged prostate. The diameter of the catheter is too large. The nurse failed to deflate the retention balloon after pretesting it for integrity. The client has an occult abscess in the urethra.

A

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.

A

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? checking that the client has signed 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

A

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 contractions. Perform these exercises 10 times daily for 1 month.

A

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.

A

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

A

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

A

The nurse is assessing a client's bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply. The nurse gently palpates the client's symphysis pubis. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. The nurse places the scanner head on the gel or gel pad, with the directional icon on the scanner head pointed away from the client's head. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). The nurse adjusts the scanner head to center the bladder image on the crossbars. The nurse presses and holds the END button until it beeps 3 times and then reads the volume measurement on the screen.

A, B, D, E

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

B

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Perform hand hygiene between cleansing the woman's labia and inserting the catheter. Insert the catheter with her left hand while supporting the woman with her right hand.

B

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

B

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately? Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container. Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. Obtained urine specimen from urinary drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port. Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure.

B

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? Loosen the internal muscles used to prevent or interrupt urination. Keep muscles contracted for at least 10 seconds. Relax muscles for at least 5 minutes between Kegels. Perform these exercises two times daily for a week.

B

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.

B

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.

C

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

C

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain? reddish-brown, clear clear, light yellow dark brown, cloudy aromatic, green

C

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority? Checking for blood return in the CVC Placing the client as N.P.O. status Notifying the health care provider of the assessment findings Obtaining laboratory studies

C

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

C

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

C

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.

C

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.

C

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

C

A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. Dry the perineal area after urination or defecation from the back to the front. Take baths instead of showers. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body.

C,D,E

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion? inability to control either urinary or bowel elimination hygiene measures used to keep meatus and adjacent area of the catheter clean use of a catheter to collect urine in a sterile environment one or both of the ureters are surgically implanted elsewhere

D

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved? Glomerulus Bowman's capsule Loop of Henle Nephron

D

A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? urge total reflex stress

D

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

D

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.

D

A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women? Contract abdominal muscles 10 times per day. Squat down and then jump up to a standing position. Lie on the floor, raise, then lower your legs 20 times per day. Contract the pubic muscles for 3 seconds, then relax.

D

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

D

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.

D

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.

D

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

D

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

D

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.

D

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

D

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

D