prep-u chapter 38

The health care provider has ordered a 24-hour urine specimen collection for a client. Which nursing action is appropriate? Select all that apply. a. Ask client to void for the last time at exactly the 24-hour mark. b. Place urine in staff refrigerator. c. Have client label own urine collection. d. Discard first urine just before starting the test, then collect urine thereafter. e. Teach client to void only one time per hour.

a. Ask client to void for the last time at exactly the 24-hour mark. d. Discard first urine just before starting the test, then collect urine thereafter.

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? a. Change to supine position. b. Examine that clothing is not constrictive on arm. c. Notify the primary health care provider. d. Instruct to not get out of bed.

a. Change to supine position.

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

a. Check health record for provider's order.

An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem? a. Discuss the use of protective undergarments to avoid embarrassment from incontinence. b. Encourage the client to confide in family members and tell them about the accidents. c. Inform the client that this is not normal and make a referral to a urologist. d. Tell the client that this happens to all people when they get older.

a. Discuss the use of protective undergarments to avoid embarrassment from incontinence.

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

a. It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

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? a. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. b. Remove the catheter from the vagina and attempt to insert it into the bladder. c. Ask the client to bear down until the catheter is expelled. d. Immediately remove the catheter from the vagina, contact the health care provider, and anticipate a prescription for prophylactic antibiotics.

a. Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

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? a. Reddened perineal skin b. Presence of smegma c. Moist perineal skin d. Absence of discharge

a. Reddened perineal skin

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? a. anuria b. urinary retention c. oliguria d. nocturia

a. anuria

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? a. functional b. urge c. total d. stress

a. functional

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? a. intermittent urethral catheter b. indwelling urethral catheter c. retention catheter d. Foley catheter

a. intermittent urethral catheter

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

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

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

b. Asking the client when he or she had last urinated

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

b. Cholinergic agents

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

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

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

b. Tighten the internal muscles used to prevent or interrupt urination.

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

b. Urinal

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? a. Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen. b. Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique. c. Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic. d. Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag.

b. Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation? a. maintaining the client without liquids before the procedure b. checking that the client has signed a consent form for the procedure c. explaining to the client that the procedure will be painful d. inserting a Foley catheter the morning of the procedure

b. checking that the client has signed a consent form for the procedure

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate? a. kidney injury b. dehydration c. hypovolemia d. balanced fluids

b. dehydration

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? a. reflect b. stress c. total d. urge

b. stress

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? a. Catch the urine in the cup after cleansing the perineum. b. the urine while holding the labia apart, after allowing the first urine to flow into the toilet. c. Catch the urine while holding the labia apart, after cleansing. Fill the specimen cup. d. Catch the urine while holding the labia apart, then cleanse each side of the labia with prepared aseptic swabs.

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

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? a. "Start collecting the urine with the next time you urinate." b. "Begin the collection when you first urinate in the morning." c. "Discard your first urine and begin the collection after that." d. "You will need to have a catheter inserted for this collection."

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

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

c. Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.

The nurse is caring for a female client with frequent urinary tract infections (UTIs). What does the nurse include in the client's teaching plan to decrease the incidence of UTIs? a. Shower rather than taking baths. b. Ensure adequate vitamin C intake. c. Be sure to urinate after you have sexual intercourse. d. Wipe the perineal area from back to front.

c. Be sure to urinate after you have sexual intercourse.

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? a. Place the client on either side and rescan. b. Wipe off some of the ultrasound gel and rescan. c. Ensure proper positioning of the scanner head and rescan. d. Have the client drink 8 ounces of water every 15 minutes for 1 hour.

c. Ensure proper positioning of the scanner head and rescan.

A client's blood urea nitrogen (BUN) test results are significantly elevated. When reviewing the client's history, which finding is consistent with BUN elevation other than renal compromise? a. The client has a history of osteoarthritis. b. The client is lactose intolerant. c. The client is dehydrated. d. The client is on a low protein diet.

c. The client is dehydrated.

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? a. The novice nurse asks the client when was the last time he voided before palpating the bladder. b. The novice nurse measures the height of the edge of the bladder above the symphysis pubis. c. The novice nurse asks the client to urinate before palpating the bladder. d. The novice nurse observes the lower abdominal wall for any swelling.

c. 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? a. Stress incontinence b. Overflow incontinence c. Total incontinence d. Functional incontinence

c. Total incontinence

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. a. Take baths instead of showers. b. Dry the perineal area after urination or defecation from the back to the front. c. Wear underwear with a cotton crotch. d. Avoid clothing that is tight and restrictive on the lower half of the body. e. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse.

c. Wear underwear with a cotton crotch. d. Avoid clothing that is tight and restrictive on the lower half of the body. e. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse.

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? a. light yellow, clear b. clear, dark amber c. cloudy, foul odor d. strongly aromatic, amber

c. cloudy, foul odor

A client is suspected of having a disease process affecting the basic functional unit of the kidney. Which structure is likely involved? a. glomerulus b. loop of Henle c. nephron d. Bowman capsule

c. nephron

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? a. casts b. protein c. pus d. calculi

c. pus

A client is brought to the emergency department (ED) after a seizure. Which type of incontinence does the nurse anticipate the client may have experienced? a. reflex b. urge c. total d. stress

c. total

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? a. "I will place a bath blanket over the client to provide privacy." b. "Washing hands before and after the procedure is important." c. "The client will be placed in a reclining position with knees bent." d. "I will use clean gloves to handle the catheter and other equipment."

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

Which statement should the nurse convey to the parent of a 3-year-old boy who has not achieved urinary continence? a. Boys may walk by 1 year and should be continent by 3 years. b. Daytime continence is usually not achieved by boys until age 5. c. Incontinence after the age of 3 years is not normal. d. Boys may take longer for daytime continence than girls.

d. Boys may take longer for daytime continence than girls.

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? a. Monitor vital signs b. Instruct on proper wiping technique c. Encourage fluids d. Contact the health care provider

d. Contact the health care provider

A nurse has been asked to speak about health promotion topics for a group of women older than 40 years of age. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the group? a. Lie on the floor, raise, then lower your legs 20 times per day. b. down and then jump up to a standing position. c. Contract abdominal muscles 10 times per day. d. Contract the pubic muscles for 3 seconds, then relax.

d. Contract the pubic muscles for 3 seconds, then relax.

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

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

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? a. Obtaining laboratory studies b. Placing the client as N.P.O. status c. Checking for blood return in the CVC d. Notifying the health care provider of the assessment findings

d. Notifying the health care provider of the assessment findings

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? a. Encouraging the client to stay close to home b. Fluid restriction c. Indwelling catheterization d. Regular toileting routine

d. Regular toileting routine

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? a. Catheterization is likely necessary for 5 to 7 days. b. A neurogenic bladder results from local anesthesia. c. A urinary tract infection can result from the birth process. d. The birth can cause perineal swelling.

d. The birth can cause perineal swelling.

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

d. The novice nurse selects an 18 French Foley catheter to insert.

A nurse is preparing to measure a client's urine output. Which interventions would be of highest priority? a. Measuring the urine container at eye level b. Using an appropriate measuring container c. Noting the color and clarity of the urine d. Wearing gloves when handling the urine

d. Wearing gloves when handling the urine

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

d. bedside commode