PPNC Exam 1 Module 5
stress urinary incontinence
Characteristics: small volume loss of urine with coughing, laughing, exercise, walking, getting up from chair. Usually does not leak at night while sleeping
functional incontinence
Characteristics: toilet access is restricted
urge/urgency urinary incontinence
Characteristics: urgency, frequency, nocturia, difficulty or inability to hold urine once the urge to avoid occurs, leaks on the way to the bathroom, leaks larger volumes of urine, strong urge/leaks whenever one hears water running, washes hands, drinks fluids
Transient incontinence
Nursing interventions: look for reversible causes and notify HCP of any suspected reversible causes
urge/urgency urinary incontinence
passage of urine associated w/ strong sense of urgency r/t overactive bladder from neurological problems, bladder inflammation, or bladder outlet obstruction; caused by involuntary contractions of the bladder associated w/ an urge to void leakage of urine
5-10 CCs
what size syringe will you utilize when obtaining a urine sample?
C
which action with the nurse Implement to prevent a client with the internet retention and an indwelling urinary catheter from developing and urinary tract infection? a. assess urine specific gravity. b. collect a weekly urine specimen. c. maintain the prescribed hydration. d. empty the drainage bag once a day.
C
which catheter would the nurse use in a primary health care provider has prescribed an indwelling urinary catheter for a client
D
A newly admitted patient has a suprapubic catheter. You notice that the site is red and leaking urine. You notify the HCP and take priority to what course of action. a. This is a normal finding b. Tell the patient he/she will need to for back to surgery c. Empty and record urine d. Monitor urine output and provide skin care
reflux urinary incontinence
CAUTION: at risk for developing autonomic dysreflexia, a life threatening condition that causes severe elevation of blood pressure and pulse rate and diaphoresis medical emergency needs immediate intervention notify HCP
foley bag; PureWick
CLINICAL JUDGMENT: NEVER obtain a sample from inside the _____ _____ or _______ container
transient incontinence
Characteristics: delirium and acute confusion, inflammation, medications, excessive urine output, mobility impairment, fecal impaction, depression, acute urinary retention
reflux urinary incontinence
Characteristics: diminished or absent awareness of bladder filling and the urge to void, leakage of urine without awareness, may not completely empty the bladder
5-15
Clinical Judgment: Failure to measure PVR ___-___ minutes after a pt. void can result in inaccurate bladder scan
functional incontinence
Nursing interventions: adequate lighting and bathroom, individualized toileting program, habit training, schedule toileting program, prompted voiding, mobility aids, toilet area cleared, elastic waist pants, nurse call system always in reach, use of incontinence containment product
urge/urgency urinary incontinence
Nursing interventions: ask patient about symptoms of a UTI, avoid bladder irritants, pelvic muscle exercises, urge inhibition exercises, bladder training, monitor patient symptoms and for presence of side effects of antimuscarinic medications
overflow urinary incontinence
Nursing interventions: individualized r/t severity; for mild—timed voiding, double voiding, monitor PVR, intermittent catheterization; severe—intermittent catheterization, indwelling catheterization
stress urinary incontinence
Nursing interventions: instruct patient in pelvic muscle exercises
adhesive tape
Never use regular ________ ________ to secure a condom catheter. Constriction from tape can reduce blood flow to tissues
reflux urinary incontinence
Nursing Intervention: follow prescribed schedule for emptying the bladder through voiding or intermittent catheterization, supply urine containment products, monitor for signs and symptoms of UTI and urinary retention, monitor for autonomic dysreflexia
D; indicates inadequate urinary voiding
The PCA has bladder scanned an adult patient to check for a post void residual (PVR). Which amount is of concern to notify the MD? Why? a 30ml b. 95ml c. 60ml d. 125ml
Shellfish; Iodine; Latex
Which allergy will be important to know prior to performing a urinary catheterization?
B
Which instruction is important for the nurse to include in discharge teaching for a client who asked to perform intermittent urinary self catheterization a. " where sterile gloves when doing the procedure" b."wash your hands before performing the procedure" c. " perform the self catheterization every 12 hours" d. " dispose of the catheter after you have catheterized yourself"
D
You are a nursing student watching a placement of a urinary catheter in a female client by an experienced RN. You notice there's a breach in sterility during the setup. What's your best course of action? a. Notify the instructor after b. Keep quiet c. Tell the RN that's not how you learned it d. Offer to obtain another sterile kit and state what was breeched
continent urinary reservoir
a surgical alternative that uses a section of the ileum/intestine to create an internal reservoir that holds urine, with the creation of a catheterizable stoma; must be emptied 4-6 times a day
orthotopic neobladder
a urinary diversion consisting of a bladder constructed from portions of intestine connected to the urethra, allowing "natural" voiding; ileal pouch replaces bladder
A
at which site would the nurse obtain a sterile urinalysis from a client with an indwelling catheter? a. tubing injection port b. distal end of the tubing c. urinary drainage bag d. catheter insertion site
transient incontinence
caused by medical conditions; temporary or occasional incontinence that is reversed when the cause is treated
ureterostomy
creation of an artificial opening into the ureter; ureter opening brought to the surface of the skin; normal for urine to be cloudy because of mucus
2-3 inches; 5-7.5 cm
how far do you insert the female catheter?
7-9 inches; 17-22.5 cm
how far do you insert the male catheter?
10 to 15 minutes
how long would you ase a clamp or rubber band to clamp the drainage tubing below the urine sampling port for?
1-2 inches; 2.5-5 cm
how much do you lubricate a female catheter
5-7 inches; 12.5-17.5 cm
how much do you lubricate a male catheter
closed system; surgical procedure
intermittent irrigation is used to keep a ______ _______ and continuous irrigation is used in _____ _______.
stress urinary incontinence
involuntary leakage of small volumes of urine associated with increased intra-abdominal pressure r/t either urethral hypermobility or an incompetent urinary sphincter; result of weakness or injury to urinary sphincter or pelvic floor muscles
reflux urinary incontinence
involuntary loss of urine at predictable intervals when pt. reaches specific bladder volume r/t spinal cord damage between C1 and S2
overflow urinary incontinence
involuntary loss of urine caused by an over distended bladder often r/t bladder outlet obstruction or poor bladder emptying b/c weak or absent bladder contractions
nephrostomy
small tubes that are tunneled through the skin into the renal pelvis
C
the family of an older adult reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter. which rational would the nurse manager consider before responding? a. procedures for a client's benefit do not require a sign consent. b. clients who are aphasic are incapable of signing and informed consent. c. a separate sign form consent for the routine treatment is unnecessary. d. I specific intervention without a client;s signed consent is an invasion of riots
functional incontinence
the person has bladder control but cannot use the toilet in time; loss of continence b/c causes outside the urinary tract, usually r/t functional deficits (altered mobility and manual dexterity, cognitive impairment, poor motivation, environmental barriers)
A
which instruction would the nurse provide a client needing to collect a clean catch urine specimen? a. urinate a small amount, stop flow, and then fill one half of the specimen cup. b. Collect a sample of the last urine voided during the night. c. if anticipating a delay and delivery, keep the urine sample in a warm dry area. d. send the urine sample to the laboratory within 6 hours of collection
C
which intervention is most beneficial in preventing CAUTI in a post-operative client? a. pouring warm water over the perineum. b. ensuring the patency of the catheter. c. removing the catheter within 24 hours. d. cleaning the catheter insertion site
A
which intervention is most important in preventing Hospital acquired catheter Associated urinary tract infections? a. removing the catheter. b. keeping the drainage bag off the floor. c. washing hands before and after assessing the catheter. d. cleansing the urinary meatus with soap and water daily
B, C, E
which intervention would help in order adult experiencing urinary incontinence? SATA. a. provide nutritional support. b. provide voiding opportunities. c. avoid indwelling catheterization. d. provide Beverages and snacks frequently. e. promote measures to prevent skin breakdown
B
which intervention would the nurse implement when providing care for an older adult male client who is immobile and incontinent of urine? a. restrict fluid intak b. regularly offer a ruinal c. apply incontinence pads d. insert an indwelling urinary catheter
overflow urinary incontinence
Characteristics: distended bladder on palpation, high PVR, frequency, involuntary leakage of small volumes of urine, nocturia
A, C, D
You are caring for an indwelling urinary catheter should include which of the following interventions? SATA a. Remove obvious encrustations from the external catheter surface by washing it gently with soap and water. b. Lay the drainage bag on the floor to allow for maximum drainage through gravity c. Keep catheter bag below bladder level d. Monitor for adequate urine output of 30ml or greater per hour
A, B
Your patient's urinalysis returns from the lab with a specific gravity of 1.060. What is this indicative of? SATA. a. Dehydration b. Reduced renal blood flow c. Overhydration d. This is a normal value
A
which evidence based nursing intervention links to reducing CAUTI in clients requiring long-term indwelling catheters? a. perform catheter care twice a day b.replace the catheter on a routine basis c. administer cranberry tablets three times a day d. administer prophylactic antibiotics twice a day for the duration of the catheter placement
D
which infection prevention technique would be appropriate for a nurse to include when teaching a client being discharged with an indwelling catheter? a. once a day, clean tubing with mild soap and water, starting at the drainage bag and moving toward the insertion site. b. after cleaning the catheter site, it is important to keep the foreskin retracted for 30 minutes to ensure adequate drying. c. Clean the insertion site daily using a solution of vinegar and water. d. keep the drainage bag below waist level
D
which instruction would the nurse give to the client having a residual urine test? a. void right after a urinary catheters removed. b. Collective specimen of urine during midstream. c. attempt to void when urinary catheter is in place. d. empty the bladder before urinary catheter is inserted
