Urinary Elimination

After surgery, a postoperative patient has not voided for 8 hours. Where would the nurse assess the bladder for distention? A) Between the symphysis pubis and the umbilicus B) Over the costovertebral region of the flank C) In the left lower quadrant of the abdomen D) Between ribs 11 and 12 and the umbilicus

A) Between the symphysis pubis and the umbilicus

A male patient who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding? A) Assist him to a standing position B) Tell him he has to void to be discharged C) Pour cold water over his genitalia D) Ask his wife to assist with the urinal

A) Assist him to a standing position

A male client who has had outpatient surgery is unable to void while lying supine. What can the nurse do to facilitate his voiding? A) Assist him to a standing position B) Tell him he has to void to be discharged C) Pour cold water over his genitalia D) Ask his wife to assist with the urinal

A) Assist him to a standing position Rationale: Helping clients assume their usual voiding positions may be all that is necessary to resolve an inability to void. If male clients cannot void lying down, encourage them to void while standing at the bedside unless this is contraindicated

After surgery, a postoperative client has not voided for eight hours. Where would the nurse assess the bladder for distention? A) Between the symphysis pubis and the umbilicus B) Over the costovertebral region of the flank C) In the left lower quadrant of the abdomen D) Between ribs 11 and 12 and the umbilicus

A) Between the symphysis pubis and the umbilicus Rationale: When the bladder is distended with urine, it rises above the symphysis pubis and may reach to just below the umbilicus. The other choices are anatomically incorrect for assessing a distended bladder

The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more than a few drops of urine in the toilet. Which is the priority assessment to be performed by the nurse? A) Bladder scan to determine the amount of urine in the bladder B) Auscultation to assess circulation through the right and left renal arteries C) Bimanual palpation to assess for possible enlargement of the kidneys D) Calculate the patient's intake and output to check for fluid volume deficit

A) Bladder scan to determine the amount of urine in the bladder Rationale: The patient with suspected urinary retention should have a bladder scan performed to determine the amount of urine in the bladder. If a significant amount of urine is found in the bladder, the provider may be notified to obtain an order for straight catheterization

An older woman who is a resident of long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging? A) Diminished kidney ability to concentrate urine B) Increased bladder muscle tone causing urinary frequency C) Increased bladder contractility causing urinary stasis D) Decreased intake of fluids during daytime hours

A) Diminished kidney ability to concentrate urine

An older woman who is resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging? A) Diminished kidney ability to concentrate urine B) Increased bladder muscle tone causing urinary frequency C) Increased bladder contractility causing urinary stasis D) Decreased intake of fluids during daytime hours

A) Diminished kidney ability to concentrate urine Rationale: Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the diminished ability to concentrate urine that may result in nocturia (voiding during the night). Aging does not result in increased bladder muscle tone or increased bladder contractility. A decrease in fluid intake would not result in nocturia

A home care patient has an indwelling catheter connected to a leg bag. What can the nurse recommend to help prevent development of a urinary tract infection? A) Empty the leg bag at regular intervals B) Always wipe from from to back after voiding C) Restrict intake of fluids to decrease amount of urine D) Take the tubing apart and wash it each day

A) Empty the leg bag at regular intervals

Which of the following describes the term microturition? A) Emptying the bladder B) Catheterizing the bladder C) Collecting a urine specimen D) Experiencing a total incontinence

A) Emptying the bladder

Which of the following describes the term micturition? A) Emptying the bladder B) Catheterizing the bladder C) Collecting a urine specimen D) Experiencing total incontinence

A) Emptying the bladder Rationale: The process of emptying the bladder is known as urination, micturition, voiding

A patient has developed edema in her lower legs and feet, prompting her physician to prescribe furosemide (Lasix), a diuretic medication. After the client has begun this new medication, what should the nurse anticipate? A) Increased output of dilute urine B) Increased urine concentration C) A risk of urinary tract infections D) Transient incontinence and increase urine production

A) Increased output of dilute urine Rationale: Diuretics results in moderate to severe increases in the production of dilute urine. Concentration will decrease, not increase, and there is no accompanying risk of urinary tract infections. For some clients, this sudden increase in urine output may precipitate transient incontinence, but this remains an abnormal finding

The nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder. Which action will thee nurse take to facilitate this procedure? A) Obtain a coudé catheter for insertion B) Attach a leg bag to the catheter prior to insertion C) Trim the pubic hair before cleaning the perineal area D) Wait until the bladder is full to perform catheterization

A) Obtain a coudé catheter for insertion Rationale: A Coudé catheter is used when there is narrowing or constriction of the urethra, making insertion of a regular indwelling catheter difficult. The Coudé catheter has a special tip on the end that is designed to facilitate insertion of the catheter through the narrowed urethra caused by BPH. Coudé catheters may need to be placed using a metal wire introducer. Placement using an introducer typically is performed by a provider or the patient's urologist, to avoid damaging urethral tissue. Trimming the pubic hair will not facilitate catheterization. Attaching a leg bag to the catheter prior to insertion is not needed because a bedside collection bag will usually be used at first

The nurse is caring for a male patient who will be performing intermittent self-catheterization at home. Which actions by the patient indicate the need for additional teaching about this procedure? (Select all that apply) A) Patency of the balloon is tested prior to insertion of the catheter B) The catheter is inserted another 2 inches after urine is seen in the tubing C) The catheter is carefully secured to the leg to prevent accidental removal D) The foreskin is returned to its natural position after the cathetr is removed E) Catheterization is performed regularly before the bladder becomes distended F) Water-soluble lubricant is generously applied along the length of the catheter

A) Patency of the balloon is tested prior to insertion of the catheter C) The catheter is carefully secured to the leg to prevent accidental removal F) Water-soluble lubricant is generously applied along the length of the catheter Rationale: Only 5-8 inches of the catheter tip are covered with water-soluble lubricant. Patency of the balloon is only checked when indwelling catheters are inserted. Intermittent catheters need not be secured to the patient's leg because they will be removed after the bladder is drained. The other actions are correct

The nurse is caring for a patient who has developed kidney failure. Which test finding leads the nurse to contact the nephrologist and arrange for emergency hemodialysis? A) Potassium level 6.8 mmol/L B) Serum creatinine level of 2.8 mg/dL C) Large amounts of protein in the urine D) 1500 mL of retained urine in the bladder

A) Potassium level of 6.8 mmol/L Rationale: Patients in a renal failure often require dialysis to reduce serum potassium levels to less than 5.5 mmol/L. Critically high serum potassium levels can lead to lethal arrhythmias and must be corrected promptly. Patients with advanced renal failure may require emergency hemodialysis if the potassium level does not lower with other methods (insulin and 50% dextrose, kayexalate). An elevated creatinine is consistent with kidney dysfunction. Large amounts of protein in the urine occurs in some diseases. 1500 mL of retained urine requires straight catheterization

The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient developed renal failure. The nurse recognizes which type of renal failure the patient most likely developed? A) Prerenal B) Renal C) Postrenal D) Mixed

A) Preprenal Rationale: Prerenal failure occurs as a result of reduction in blood flow to the kidneys, which would occur with septic shock. Causes of prerenal failure include dehydration, vascular collapse, and low cardiac output. Structural issues with the kidneys, from primary glomerular diseases of vascular lesions, result in renal failure. Postrenal failure is related to a mechanical or functional obstruction of the flow of urine.

The nurse is caring for a patient with an indwelling urinary catheter caused by severe prostate enlargement. Which is the priority nursing diagnosis for this patient? A) Risk for infection r/t indwelling urinary catheter B) Disturbed body image r/t presence of catheter C) Risk for contamination r/t potential leakage of urine on cloting D) Impaired urination r/t blockage of bladder outlet

A) Risk for infection r/t indwelling urinary catheter Rationale: The presence of an indwelling urinary catheter puts the patient at high risk for urinary tract infection, and this is the highest priority diagnosis for the patient. Disturbed body image is not as important as the risk of infection. Risk for contamination is not a nursing diagnosis. Impaired urination was corrected by placement of the urinary catheter

An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses? A) Social Isolation B) Impaired Adjustment C) Defensive Coping D) Impaired Memory

A) Social Isolation

An older adult woman has constant dribbling of urine. The associated discomfort, odor, and embarrassment may support which of the following nursing diagnoses? A) Social Isolation B) Impaired Adjustment C) Defensive Coping D) Impaired Memory

A) Social Isolation Rationale: Incontinence is a special problem for older adults who may have decreasing control over micturition, or find it more difficult to reach the toilet in time. The discomfort, odor, and embarrassment of urine-soaked clothing can greatly diminish a person's self-concept, causing him or her to feel like a social outcast

The nurse is caring for a patient with the nursing diagnosis of Urge incontinence of urine related to urinary tract infection. Which statement is appropriate for the "as evidenced by" portion of the patient's diagnosis? A) Sudden leakage of urine when patient is unable to get to the toilet in time B) Continuous urine flow from the bladder regardless of attempts to use the toilet C) Leakage of urine from the bladder when the patient coughs, sneezes, or laughs D) Leakage of urine because the patient is unable to indicate need to use the toilet

A) Sudden leakage of urine when patient is unable to get to the toilet in time Rationale: Urge incontinence of urine occurs when the patient has a sudden need to urinate but cannot get to the toilet in the time. Continuous flow of urine is deemed total urinary incontinence. Leakage of urine when sneezing or coughing is stress incontinence. Functional incontinence occurs when the patient cannot indicate need to use the toilet

A nurse is using a bladder scanner to assess the bladder volume of a client with urinary frequency. In which of the following would the nurse place the client? A) Supine B) Sims' C) High Fowler's D) Dorsal recumbent

A) Supine Rationale: Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Results are most accurate when the client is in the supine position during the scanning

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A) Suprapubic catheter B) Indwelling urethral catheter C) Intermittent urethral catheter D) Straight catheter

A) Suprapubic catheter Rationale: A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra

The student nurse studying the anatomy and physiology of the urinary system knows that the following are functions of the bladder. Select all that apply A) The bladder serves as a temporary reservoir for urine B) The sympathetic system carries inhibitory C) Urine from the bladder empties into the pelvis of each kidney D) A fold of membrane in the bladder closes the entrance to the ureters when pressure exists E) The parasympathetic system carries motor impulses to the bladder and inhibitory impulses to the internal sphincter F) From the bladder, urine is transported by rhythmic peristalsis through the ureters to the kidneys

A) The bladder serves as a temporary reservoir for urine B) The sympathetic system carries inhibitory D) A fold of membrane in the bladder closes the entrance to the ureters when pressure exists E) The parasympathetic system carries motor impulses to the bladder and inhibitory impulses to the internal sphincter

During a visit to the pediatrician's office, a parent inquires about toilet training her daughter age 2 years. The nurse informs the mother that one factor in determining toilet-training readiness is when... A) The child can recognize bladder fullness B) The child can hold the urine for four five hours C) The child cannot urination until seated on the toilet D) The child ignores the desire to void

A) The child can recognize bladder fullness Rationale: Toilet training usually begins around ages 2 or 3 years. Toilet training should not begin until the child is able to hold urine for two hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet

The nurse is working with a new nursing assistant who is providing care to patients with urinary difficulties. Which actions by the nursing assistant indicates that additional teaching is required? (Select all that apply) A) The length of the urinary catheter is cleaned up to the patient's perineum B) A urine sample is obtained from the drainage bag immediately after catheter insertion C) A fresh condom catheter is applied every other day following careful perineal care D) Zinc oxide barrier cream is applied liberally to the perineal area for incontinent patients E) The catheter drainage bag is disconnected in order to put pants on the patient F) Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter

A) The length of the urinary catheter is cleaned up to the patient's perineum C) A fresh condom catheter is applied every other day following careful perineal care E) The catheter drainage bag is disconnected in order to put pants on the patient F) Clean technique is used to obtain a urine specimen for culture and sensitivity from the catheter Rationale: The urinary catheter must be cleaned from the urinary meatus down toward the drainage bag rather than up toward the perineum. A fresh condom catheter must be applied daily. The catheter drainage bag should not be disconnected to put pants on the patient. The drainage bag can be threaded through the pants leg before putting pants on the patients. Sterile technique should be used to obtain samples from the catheter.

The nurse is caring for a patient with a history of type 1 diabetes. Which assessment finding indicates to the nurse that the patient may not be compliant with the diabetic treatment regimen? A) The patient is always thirsty and frequently voids very large amounts of urine B) The patient's urine is very concentrated with a dark amber color C) The patient complains of throbbing flank pain and burning with urination D) The patient has urinary hesitancy and difficulty initiating a stream of urine

A) The patient is always thirsty and frequently voids very large amounts of urine Rationale: A non compliant diabetic patient will have elevated blood sugars that cause thirst and polyuria. Concentrated urine indicates dehydration. Throbbing flank pain and burning with urination are indicative of urinary tract infection. Urinary hesitancy and difficulty initiating urine stream are not indicative of elevated blood sugar levels

A nurse is assessing the urine output of a patient with Parkinson's disease who is on levodopa. Which of the following is a common finding for a patient on this medication? A) The urine may be brown or black B) The urine may be blood tinged C) The urine may be green or blue-green D) The urine may be orange or orange-red

A) The urine may be brown or black

A nurse is assessing the urine output of a client with Parkinson's disease who is on levodopa. Which of the following is a common finding for a client on this medication? A) The urine may be brown or black B) The urine may be blood-tinged C) The urine may be green or blue-green D) The urine may be orange or orange-red

A) The urine may be brown or black Levodopa (l-dopa), an antiparkinson drug, and injectable iron compounds can lead to brown or black urine. Anticoagulants may cause hematuria (blood in the urine), leading to a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine (Pyridium), a urinary tract analgesic, can cause or orange-red urine

The nurse is caring for an elderly patient whose dementia has become worse over the last 24 hours. The nurse suspects that the patient may have developed a urinary tract infection and obtains a urine sample. Which assessment findings prompt the nurse to contact the provider to obtain and order for urine culture and sensitivity testing? (Select all that apply) A) Urinary dipstick testing is positive for nitrates B) The urine appears cloudy with a foul odor C) The urine is concentrated and dark amber in color D) The urine smells faintly like sweet fruit E) The patient is urinating more frequently than usual F) The patient is normally continent but has been incontinent twice

A) Urinary dipstick testing is positive for nitrates B) The urine appears cloudy with a foul odor E) The patient is urinating more frequently than usual F) The patient is normally continent but has been incontinent twice Rationale: Concentrated dark urine indicates dehydration rather than infection of the urinary tract. Urine that smells of sweet fruit contains ketones from high blood sugar. Urine that is cloudy with a foul odor and positive for nitrites is most likely due to urinary tract infection. Frequent urination and incontinence are signs of urinary tract infection in the elderly

A patient tells the nurse, every time I sneeze, I wet my pants. What is this type of involuntary escape urine called? A) Urinary incontinence B) Urinary incompetence C) Normal micturition D) Uncontrolled voiding

A) Urinary incontinence

A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? A) Urinary incontinence B) Urinary incompetence C) Normal micturition D) Uncontrolled voiding

A) Urinary incontinence Rationale: The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence

A nurse is initiating a 24-hour urine collection for a patient at home. What will be the first thing the nurse will ask the patient to do at the beginning of the specimen collection? A) Void and discard the urine B) Begin the collection at a specific time C) Add the first voiding to the specimen D) Keep the urine warm during collection

A) Void and discard the urine

A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risks should the nurse discuss with this client? A) Public embarrassment B) Skin breakdown and UTI C) Inability to control urine D) Odor and leake

B) Skin breakdown and UTI Rationale: Clients frequently turn to absorbent products for protection when they are incontinent oof urine and if they have not had this condition properly diagnosed and treated. When used improperly, such products may cause skin breakdown and place the client at risk for a UTI

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection? A) Void and discard the urine B) Begin the collection at a specific time C) Add the first avoid to the specimen D) Keep the urine warm during collection

A) Void and discard the urine Rationale: The collection is initiated at a specific time, but the client is asked to void at that time and discard the urine from the first voiding. In most instances, a preservative is added to the collection bottle, or the collected urine is kept cold through refrigeration or putting it on ice

What is the micturition reflex? A) The process of filtration beginning with the glomerulus B) The act of bladder contraction and perceived need to void C) The reabsorption of the substances the body wants to retain D) The secretion of electrolytes that are harmful to the body

B) The act of bladder contraction and perceived need to void Rationale: Several words are used to describe the process of excreting urine from the body, including urination, voiding, and micturition

A client with urinary tract infection is to be discharged from the health care facility. After teaching the client about measures to prevent urinary tract infections, the nurse determines that the education was successful when the client states which of the following? A) "I should take frequent bubble baths." B) "I need to void after sexual intercourse." C) "I should wipe from back to front after going back to the bathroom." D) "I need to wear pants that are snug fitting."

B) "I need to void after sexual intercourse." Rationale: The client's statement about voiding after sexual intercourse to prevent urinary tract infection is accurate. Taking frequent bubble baths, wiping the perineum from back to front, and wearing snug fitting pants increase the risk of urinary tract infection. The client should avoid taking frequent bubble baths, using harsh soaps, and wearing tight-fitting pants because they can irritate the urethra. The client also should always wipe from front to back after urinary or fecal elimination

The nurse is caring for a patient who will undergo ultrasound testing of the bladder and kidneys the next morning Which instruction will the nurse provide to the patient about the test? A) "A small IV will be inserted into your arm to inject the contrast dye." B) "You will need to drink lots of water but not use the toilet." C) "You should not have anything to eat or drink after midnight." D) "You will receive a cleansing enema before you have the test."

B) "You will need to drink lots of water but not use the toilet." Rationale: No preparation is needed for kidney and bladder ultrasound other than having the patient drink lots of fluid beforehand. The patient is instructed not to use the toilet so that the bladder will be filled and easy to visualize. No contrast dye, enemas, or fasting is required

A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A) A clean catheter and rubber gloves B) A sterile catheterization kit or tray C) Solutions to sterilize the urethra D) Solutions to sterilize the vagina

B) A sterile catheterization kit or tray

A nurse is inserting an indwelling urethral catheter. What type of supplies will the nurse need for this procedure? A) A clean catheter and rubber gloves B) A sterile catheterization kit or tray C) Solutions to sterilize the urethra D) Solutions to sterilize the vagina

B) A sterilize catheterization kit or tray Rationale: The bladder is a sterile environment. The urethra and vagina cannot be sterilized. The equipment used for catheterization is usually prepackaged in a sterile disposable kit or tray

A client is admitted to the health care facility with complains of pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as which of the following? A) Polyuria B) Dysuria C) Nocturia D) Hematuria

B) Dysuria Rationale: Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a burning sensation during urination. Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent, increase in fluid intake. Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood in the urine.

The nurse is caring for a patient who had a prostate surgery the previous day. The patient has had significantly decreased urine output over the last shift despite ample oral and IV fluid intake. The patient's urine from the indwelling catheter is cherry reed with occasional small clots. What is the appropriate action of the nurse? A) Remove the urinary catheter and replace it with a new one B) Gently irrigate the catheter using warmed sterile normal saline C) Send a sample of the patient's urine to the laboratory for analysis D) Call the provider and obtain and order for kidney and bladder ultrasound

B) Gently irrigate the catheter using warmed sterile normal saline Rationale: The patient most likely has decreased urine output caused by clot formation that is blocking urine from draining through the catheter. The catheter should be gently irrigated using sterile technique and warmed sterile saline to loosen clots and facilitate urinary drainage. The catheter should not be removed. Ultrasound and urinalysis are not necessary

A nurse is conducting a health history interview for an office patient who is having problems with urinary control. What would be an appropriate interview question to collect further data? A) Why don't you go to the bathroom more? B) How have you handled this problem? C) What does your wife think about this problem? D) What makes you think you have a problem?

B) How have you handled this problem?

The nurse should is caring for a patient who is to complete a 24-hour urine collection to measure creatinine clearance. Which tasks related to this test may be delegated to the nursing assistant? (Select all that apply) A) Teaching the patient about sterile specimen collection B) Keeping the urine collection container cool on ice C) Dumping the urine from the patient's first void D) Restricting the patient's oral fluid intake during the test E) Transporting the specimen to the laboratory for testing F) Reminding the patient not to put toilet paper in the urine

B) Keeping the urine collection container cool on ice C) Dumping the urine from the patient's first void E) Transporting the specimen to the laboratory for testing F) Reminding the patient not to put toilet paper in the urine Rationale the nurse assistant can help the nurse by keeping the urine collection container cool on ice dumping the urine from the patient's first void, and reminding the patient not to put toilet tissue in the urine specimen. The nurse assistant can also transport the specimen to the laboratory after the urine has been collected for 24 hours. Fluid intake should be encouraged during the test. Teaching the patient about the testing procedure is done by the nurse, although creatinine clearance testing does not require sterile technique

An elderly woman living alone at home is incontinent of urine. Which of the following nursing diagnoses would be appropriate for a plan of care? A) Risk for activity intolerance B) Risk for impaired skin integrity C) Risk for falls D) Risk for infection

B) Risk for impaired skin integrity

The home health nurse is caring for an older adult woman living alone at home who is incontinent of urine and changes her adult diaper daily. Which of the following nursing diagnosis is the most appropriate for this client? A) Risk for activity intolerance B) Risk for impaired skin integrity C) Risk for infection D) Risk for falls

B) Risk for impaired skin integrity Rationale: A client who is incontinent, utilizes adult diapers, and only changes them daily is at Risk for Impaired Skin Integrity in the genital and perineal area

A man with urinary incontinence tells the nurse he wears adult diapers for protection. What risk should the nurse discuss with this patient? A) Public embarrassment B) Skin breakdown and UTI C) Inability to control urine D) Odor and leakage

B) Skin breakdown and UTI

The nurse is caring for a patient who is to undergo computed tomography (CT) of the kidneys and ureters. Which assessment finding by the nurse must be reported to the provider and radiologist before the patient has the procedure? A) The patient is allergic to bananas and latex B) The patient thinks that she might be pregnant C) The patient has a family history of bladder cancer D) The patient currently has a urinary tract infection

B) The patient thinks that she might be pregnant Rationale: CT requires exposure to radiation similar to an x-ay, so the patient's provider and radiologist should be notified promptly of the possibility of pregnancy. The other conditions do not preclude CT scan examination for the patient

The nurse is caring for an elderly patient with a history of arthritis, urinary incontinence and poor perineal hygiene practices. The patient has had four urinary tract infections in the past year. Which is the priority goal for the nursing diagnosis Impaired health maintenance for this patient? A) The patient will be provided with educational materials about risks of urosepsis B) The patient will allow family members to assist with daily bathing and perineal care C) The patient will discuss the possible consequences of frequent UTIs D) Regular home care nursing visits and follow-up telephone contact will be arranged

B) The patient will allow family members to assist with daily bathing and perineal care Rationale: The priority for this patient is to improve person hygiene and perineal care in order to reduce the risk of future urinary tract infections. The patient's agreement to allow family members to assist with bathing and perineal care will greatly reduce this risk. Providing educational materials about the risk of urosepsis, discussion of UTI consequences and regular follow-up care are interventions rather than patient goals

The nurse is caring for a patient who is experiencing stress incontinence. The nurse identifies which goal to be the most important for this patient? A) The patient will carefully complete a voiding diary for the duration of 2 weeks B) The patient will not experience involuntary urination during coughing or sneezing C) The patient will be able to recognize and effectively manage perineal dermatitis D) The patient will demonstrate how to appropriately use urinary incontinence products

B) The patient will not experience involuntary urination during coughing or sneezing Rationale: The patient with stress incontinence experiences loss of urine when coughing, sneezing, laughing, or exercising. The highest priority goal for this patient is to not experience incontinence at all and remain continent through all daily activities. If the patient remains continent, perineal dermatitis will not be a problem and urinary incontinence products will not be needed

The nurse is caring for a seriously ill patient whose laboratory results show a serum creatinine level of 3.5 mg/dL and a serum BUN of 35 mg/dL. Which conclusion can the nurse draw from these test results? A) The patient is severely dehydrated B) The patient's kidneys have been damaged C) The patient has a urinary tract infection D) The patient has developed a renal calculus

B) The patient's kidneys have been damaged Rationale: Elevated BUN and creatinine are found in laboratory test results when the kidneys have been damaged and are unable to sufficiently clear metabolic wastes from the bloodstream. A dehydrated patient may have an elevated BUN, but the serum creatinine should be normal. Urinary tract infection and kidney store (renal calculus) would not cause elevated BUN and creatinine leve.s

During a health history interview, a male patient tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnoses with enlarged prostate. What is the name of this symptom? A) Urinary incontinence B) Urinary retention C) Involuntary voiding D) Urinary frequency

B) Urinary retention

During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. He has been diagnosed with an enlarged prostate. What is the name of this symptom? A) Urinary incontinence B) Urinary retention C) Involuntary voiding D) Urinary frequency

B) Urinary retention Rationale: Urinary retention occurs when urine is produced normally but not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Incontinence is involuntary loss of urine from the bladder. Retention is an accumulation of urine in the bladder. Frequency is voiding more often that usual

A nurse has instructed a client at the clinic about collecting a specimen for a routine urinalysis. The client makes the following statements. Which one indicates a need for more teaching? A) "I will need to tell you that I am having my menstrual period." B) "I will void into the specimen bottle you gave me." C) "I will keep the toilet paper in the specimen. D) "I will be sure that no stool is included in my urine."

C) "I will keep the toilet paper in the specimen." Rationale: Urine for a routine urinalysis does not have to be sterile. Ask the client to avoid into a clean receptacle and void contamination with stool. Note on the request form if a woman is having her menstrual period. Instruct clients not to put toilet paper into the urine because this makes analysis more difficult

A nurse is teaching a patient about the amount of water to drink each day. What is the recommended daily fluid intake for adults? A) 1 to 2 (4-oz) glasses per day B) 5 to 6 (6-oz) glasses per day C) 8 to 10 (8-oz) glasses per day D) 16 to 20 (12-oz) glasses per day

C) 8 to 10 (8-oz) glasses per day

A nurse is educating a client on the amount of water to drink each day. What is the recommended daily fluid intake for adults? A) 1 to 2 (4-oz) glasses per day B) 5 to 6 (6-oz) glasses per day C) 8 to 10 (8-oz) glasses per day D) 16 to 20 (12-oz) glasses per day

C) 8 to 10 (8-oz) glasses per day Rationale: Adults with no disease-related fluid restrictions should drink 2,000-2,4000 mL (8-10 80oz glasses) of fluid daily. Monitor fluid intake for those that are high in caffeine, sodium, and sugar

A patient is taking diuretics. What should the nurse teach the patient about his urine? A) Urinary output will be decreased B) Urinary output will be increased C) Urine will be a pale yellow color D) Urine may be brown or black

C) A client is taking diuretics. What should the nurse teach the client about his urine?

A nurse is assessing the urine on a newborns diaper. What would be a normal assessment finding? A) Scanty to no urine B) Highly concentrated urine C) Light in color and odorless D) Dark in color and odorous

C) Light in color and odorless

A nurse is assessing the urine on a newborn's diaper. What should be a normal assessment finding? A) Scanty to no urine B) Highly concentrated urine C) Light in color and odorless D) Dark in color and odorous

C) Light in color and odorless Rationale: Infants are born with little ability to concentrate urine. An infant's urine is usually very light in color and without odor until about 6 weeks of age, when the nephrons are able to control reabsorption of fluids and effectively concentrate urine. Infants do not normally have scanty, highly concentrated, or dark and odorous urine.

The nurse is caring for an incontinent male patient who has a deep decubitus ulcer on his sacrum. Which intervention will best manage the patient's urinary incontinence and facilitate healing of the ulcer? A) Use of disposable absorbable incontinence briefs B) Daily application of perineal barrier cream containing zinc oxide C) Careful perineal care and application of a condom catheter D) Insertion of a single-lumen straight urinary catheter

C) Careful perineal care and application of a condom catheter Rationale: Condom catheters allow for collection of urine in the incontinent patient without the infection risks oof an indwelling catheter. The condom catheter is applied to the outside of the penis like a condom instead of being inserted into the urethra. Careful perineal care is performed prior to application of the condom catheter and regularly thereafter. Use of disposable briefs or perineal barrier cream will not facilitate healing of the sacral ulcer. A single-lumen straight urinary catheter is used to drain the bladder to relieve urinary retention or to obtain a urine sample for testing. A straight catheter is not used for management for incontinence.

A nurse is caring for elderly patients in an assisted-living facility. Which of the following effects of aging should the nurse consider when performing a urinary assessment? A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection B) Increased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in frequency C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection D) Neuromuscular problems may result in the patient finding urinary control too much trouble, resulting in incontinencee

C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection

A nurse is caring for adult clients in an assisted-living facility. Which effect of aging should the nurse consider when performing a urinary assessment? A) The diminished ability of the kidneys to concentrate urine may result in urinary tract infection B) Increased bladder tone may reduce the capacity of the bladder to hold urine, resulting in frequency C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection D) Neuromuscular problems may result in the client finding urinary control too much trouble, resulting in incontinence

C) Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection Rationale: Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. The diminished ability of kidneys to concentrate urine may result in nocturia (urination during the night). Decreased muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control and the ability to reach a toilet in time. Individuals who view themselves as old, powerless, and neglected may cease to value voluntary control over urination, and simply find toileting too much bother no matter what the setting. Incontinence may be the result

A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next? A) Report this abnormal finding to the physician. B) Perform another catheterization to verify the amount. C) Document this normal finding for postvoid residual. D) Palpate the abdomen for a distended bladder.

C) Document this normal finding for postvoid residual Rationale: A postvoid residual (PVR) urine measures the amount of urine remaining in the bladder after voiding. It can be measured by catheterization or a bladder scan. A PVR of less than 50 mL indicates adequate bladder emptying. The nurse would document this normal finding for PVR

A nurse has catheterized a patient to obtain urine to measure postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next? A) Report this abnormal finding to the physician. B) Perform another catheterization to verify the amount. C) Document this normal finding for postvoid residual. D) Palpate the abdomen for a distended bladder.

C) Document this normal finding for postvoid residual.

A nurse has instructed a clinic patient about collecting a specimen for a routine urinalysis. The patient makes the following statements. Which one indicates a need for more teaching? A) I need to tell you that I am having my menstrual period B) I will void into the specimen bottle you gave me C) I will keep the toilet paper in the specimen D) I will be sure that no stool is included in my urine

C) I will keep the toilet paper in the specimen

The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant urge to urinate but cannot pass more than 30-60 mL of urine at a time. The nurse performs a bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority nursing diagnosis for this patient? A) Anxiety r/t continual urge to urinate B) Reflex incontinence of urine r/t over-distention of the bladder C) Impaired urination r/t obstruction of urinary bladder outlet D) Impaired self-toileting r/t inability to pass urine into the toilet

C) Impaired urination r/t obstruction of urinary bladder outlet Rationale: The patient has acute urinary retention with overflow as evidenced by 1100 mL of urine in the bladder and frequent passage of small amounts of urine. The priority nursing diagnosis is thus Impaired urination r/t obstruction of small amounts oof urine. Urinary retention is the cause of the patient's discomfort and drainage of the bladder will result in relief of the patient's symptoms. The patient is able to get himself on and off the toilet so toileting self-care deficit is not a problem. Reflex incontinence of urine r/t over-distention for the bladder is not as specific to this scenario as the nursing diagnosis of impaired urination.

The nurse is caring for a patient who recently underwent ileal conduit surgery. Which nursing diagnosis is the highest priority for this patient? A) Impaired sexual function related to changed body structure B) Social isolation related to potential for accidental leakage of urine C) Lack of knowledge related to care and maintenance of ostomy appliance D) Disturbed body image related to presence of stoma and appliance

C) Lack of knowledge related to care and maintenance of ostomy appliance Rationale: The patient with a new ileal conduit needs to learn how to care for the urinary stoma and appliance prior to discharge from the hospital. If the appliance is not used and applied correctly, the patient may experience urinary leakage and significant skin breakdown from exposure to urine. The other diagnises are less important that the patient's lack of knowledge about ostomy care.

The nurse is caring for a patient with neurological condition that causes constant severe thirst, drinking fluids continuously, and voiding 3 to 4 L of clear yellow urine daily. Which term will the nurse use in the record to describe this patient's urinary output? A) Anuria B) Oliguria C) Polyuria D) Eneuresis

C) Polyuria Rationale: Urinary output greater than 2500 mL/day is polyuria. Insufficient urine output is oliguria, whereas absence of urine is anuria. Enuresis is commonly known as "bedwetting" at night

A nurse is preparing to catheterize a female patient. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra? A) Has different innvervation B) No connection with bladder C) Shorter in length D) Longer in length

C) Shorter in length

A nurse is preparing to catheterize a female client. What will the nurse consider when comparing the anatomy of the female urethra with that of the male urethra? A) Has different innervation B) No connection with bladder C) Shorter in length D) Longer in length

C) Shorter in length Rationale: The anatomy of urethra differs in males and females. The urethra is about 5 1/2 to 6 1/4 inches (13.7-16.2cm) long. The female urethra is about 1 1/2-2 1/2 inches (3.7-6.2cm) long. This difference is important in terms of catheterization and risk for infection

A nurse uses a catheter to collect a sterile urine specimen from a client at a health care facility. If a catheter is required temporarily, which type of catheter should the nurse use? A) Condom catheter B) Urinary bag C) Straight catheter D) Retention catheter

C) Straight catheter Rationale: The nurse should use a straight catheter to collect a sterile urine specimen from the client. A straight catheter is a urine drainage tube inserted but not left in place. It drains urine temporarily or provides a sterile urine specimen. Condom catheters are helpful for clients with urinary incontinence receiving care at home because they are easy to apply. A urinary bag is more often used to collect urine specimens from infants. A retention catheter also called an indwelling catheter is left in place for a period of time

A nurse working in a community pediatric clinic explains the process of toilet training to mothers of toddlers. Which of the following is a recommended guideline for initiating this training? A) The child should be able to hold urine for 4 hours B) The child should be between 18-24 months old C) The child should be able to communicate the need to void D) The child does not need to desire gain control of voiding

C) The child should be able to communicate the need to void

A nurse working in a community pediatric clinical explains the process of toilet training to mothers of toddlers. Which is a recommended guideline for initiating this training? A) The child should be able to hold urine for four hours B) The child should be between 18 and 24 months old C) The child should be able to communicate the need to void D) The child does not need to desire to gain control of voiding

C) The child should be able to communicate the need to void Rationale: Voluntary control of the urethral sphincters occurs between 18 and 24 months of age. However, many other factors are required to achieve conscious control of bladder function, and toilet training usually begins at about 2-3 years of age. The toilet training should not begin until the child is able to hold urine for 2 hours, recognize the feeling of bladder fullness, communicate the need to void, and control urination until seated on the toilet. The child's desire to gain control is also important

A patient complains of having to void frequently, burning on urination, and odorous urine. Based on these assessment findings, the nurse would suspect the patient has which of the following conditions? A) Stress incontinence B) Urge incontinence C) Urinary tract infection D) Lower colon infection

C) Urinary tract infection

A client is taking diuretics. What should the nurse teach the client about his urine? A) Urinary output will be decreased B) Urinary output will be increased C) Urine will be a pale yellow color D) Urine may be brown or black

C) Urine will be a pale yellow color Rationale: Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The nurse should inform the client about this side effect of the medication

A client has been taught to do Kegel exercised. What statement by the client indicates a need for further information? A) "I understand these will help me control stress incontinence." B) "I know this is also called pelvic floor muscle training." C) "I will do these 30-80 times a day for 2 months." D) "I will contract the muscles in my abdomen and thighs."

D) "I will contract the muscles in my abdomen and thighs." Rationale: Kegel exercises, or pelvic floor muscle training are used to tone and strengthen the muscles that support the bladder. They can improve voluntary control of urination and thus improve or eliminate stress incontinence. The muscles to contact are the same ones used to stop urination midstream or control defecation. The client should not contract the muscles of the abdomen, inner thigh, or buttocks while doing Kegel exercises

A school nurse is educating a class of middle-school girls on how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information? A) "I will take showers rather than baths." B) "I will wear underpants with cotton crotches." C) "I will tell my parents if I have burning or pain." D) "I will wipe back to front after going to the toilet."

D) "I will wipe back to front after going to the toilet." Rationale: Teaching about measures to promote urinary system health is a major nursing responsibility. Measures include the perineal area after urination or defecation from the front to the back (or from urethra to rectum)

A nurse is preparing a client for an invasive diagnostic procedure of the urinary system. What statement by the nurse would help reduce the client's anxiety? A) "We do these procedures every day, so you don't need to worry." B) " I have had this done to me, and it only hurt for a little while." C) "Why are you so worried? Do you think you have a tumor?" D) "Let me explain to you what they do during this procedure."

D) "Let me explain to you what they do during this procedure." Rationale: Various diagnostic procedures, typically performed in a hospital operating or outpatient facility, are used to study the urinary system. Nurses are responsible for preparing the client and giving aftercare. Explaining the procedure helps reduce the client's anxiety

A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen? A) Pour urine from the collecting bag B) Remove the catheter and ask the patient to void C) Aspirate urine from the collecting bag D) Aspirate urine from the collection port

D) Aspirate urine from the collection port

A student is collecting a sterile urine specimen from an indwelling catheter. How will the student correctly obtain the specimen? A) Pour urine from the collecting bag B) Remove the catheter and ask the client to void C) Aspirate urine from the collection bag D) Aspirate urine from the collection port

D) Aspirate urine from the collection port Rationale: When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should always be obtained from the catheter itself using the special collection port

A nurse is caring for a client who is being treated for bladder infection. The client complains to the nurse that he has been having difficulty voiding and feels uncomfortable. How should the nurse document the client's condition? A) Anuria B) Oliguria C) Polyuria D) Dysuria

D) Dysuria Rationale: The nurse could document the client's condition as dysuria, which is difficulty or discomfort when voiding. Dysuria is a common symptom of trauma to the urethra or bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24 hours. Oliguria indicates inadequate elimination of urine. Polyuria is the term used to indicate greater than normal urinary volume, and may accompany minor dietary variations

A patient has been taught how to do Kegel exercises. What statements by the patient indicates a need for further information? A) I understand these will help me control stress incontinence B) I know this is also called pelvic floor muscle training C) I will do these 30-80 times a day for 2 months D) I will contract the muscles in my abdomen and thighs

D) I will contract the muscles in my abdomen and thighs

A school nurse is teaching a class of middle-school girls how to promote urinary system health. Which of the following statements by one of the girls indicates a need for more information? A) I will take showers rather than baths B) I will wear underpants with cotton crotches C) I will tell my parents if I have burning or pain D) I will wipe back to front after going to the toilet

D) I will wipe back to front after going to the toilet

A nurse is preparing a patient for an invasive diagnostic procedure of the urinary system. statement by the nurse would help reduce the patients anxiety? A) We do these procedures everyday, so you don't need to worry B) I have had this done to me, and it only hurt for a little white C) Why are you so worried? Do you think you have a tumor? D) Let me explain to you what they do during this procedure

D) Let me explain to you what they do during this procedure

The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours previously. The patient has not been able to void since the catheter was removed and now reports suprapubic pain. What is the priority action of the nurse? A) Encourage oral fluid intake and administer a diuretic B) Obtain a urine sample to test for culture and sensitivity C) Calculate the patient's daily intake and output D) Obtain and order to straight-catheterize the patient

D) Obtain and order to straight-catheterize the patient Rationale: The patient who has not voided for 6-8 hours after urinary catheter removal and is complaining of suprapubic pain has acute urinary retention. The physician should be notified to obtain an order for straight catheterization to drain the bladder. A urine sample for culture and sensitivity is not ordered. Encouraging fluid intake and administering a diuretic will increase the amount of urine in the bladder and make the patient even more uncomfortable

The nurse is caring for a patient who has urinary frequency. Which nursing diagnosis is the highest priority for this patient? A) Impaired urination r/t occasional incontinence B) Anxiety r/t living alone at home with nocturia C) Risk for infection r/t urine contact with perineal area skin D) Risk for fall-related injury r/t hurried trips to the bathroom during the day and night

D) Risk for fall-related injury r/t hurried trips to the bathroom during the day and night Rationale: Risk for falls is the highest priority diagnosis for this patient because rushing to the bathroom can lead to loss of balance and serious injury. Walking to the bathroom at night is even more dangerous because of low lighting conditions and sleepiness. The other nursing diagnosis may be appropriate but not higher than the injury risk

The preceptor is watching a nursing student care for a male patient who requires a condom catheter. Which action by the nursing student indicates that the procedure is performed correctly? A) Sterile gloves are donned before touching the catheter. B) Adhesive tape is applied securely around the base of the penis. C) Water-soluble lubricant is applied to the end of the catheter. D) The foreskin is returned to its natural position before the catheter is applied.

D) The foreskin is returned to its natural position before the catheter is applied. Rationale: The patient's penis should be cleaned with soap and water with the foreskin retracted prior to condom catheter application. The foreskin should then be returned to its natural position before the catheter application. The foreskin should then be returned to its natural position before the catheter is applied. Adhesive tape should never be applied around the base of the penis because circulation may be compromised. Sterile gloves and lubricant are not needed

A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill? A) Deflate the balloon by aspirating the fluid. B) Ask the client to take several deep breaths. C) Tell the client burning may initially occur. D) Wash hands and put on gloves.

D) Wash hands and put on gloves Rationale: Although all the steps listed are correct, the first step of any skill involving body fluids is to wash hands and put gloves

A nurse is carrying out an order to remove an indwelling catheter. What is the first step of this skill? A) Deflate the balloon by aspirating the fluid. B) Ask the client to take several deep breaths. C) Tell the client burning may initially occur. D) Wash hands and put on gloves.

D) Wash hands and put on gloves.

A nurse is delegating the collection of urinary output to an assistant. What should the nurse tell the assistant to do while measuring the urine? A) Compare the amount of output with intake B) Use a clean measuring cup for each voiding C) Tell the client to wash the urethra before voiding D) Wear gloves when handling a client's urine

D) Wear gloves when handling a client's urine Rationale: Gloves are required when handling urine to prevent exposure to pathogenic microorganisms or blood that may be present in the urine. In addition, goggles are also worn if there is a concern of urine splashing

A nurse is delegating the collection of urinary output to an assistant. What would the nurse tell the assistant do while measuring the urine? A) Compare the amount of output and intake B) Use a clean measuring cup for each voiding C) Tell the patient to wash the urethra before voiding D) Wear gloves when handling a patient's urine

D) Wear gloves when handling a patient's urine