Urinary Elimination
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? "I will place a bath blanket over the client to provide privacy." "The client will be placed in a reclining position with knees bent." "I will use clean gloves to handle the catheter and other equipment." "Washing hands before and after the procedure is important."
"I will use clean gloves to handle the catheter and other equipment." Rationale-Sterile gloves are required for catheterization.
A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training? "Your child will tell you when there is a sensation of bladder fullness." "One signal of preparedness is when your child is dry for at least 2 hours." "Your child should be at least 2 years old before you start toilet training." "Girls typically take longer than boys to be ready for toilet training."
"One signal of preparedness is when your child is dry for at least 2 hours."
Which scenario does not illustrate a normal lifespan variant regarding urination? An 8-year-old is continent during the day but is incontinent 2 times during the night. A toddler age 3 1/2 is showing interest in being ready for toilet training by showing that he can undress himself and by being able to stay dry for 2 hours at a time. The urine of a neonate, 5 hours old, appears pink-tinged. A 10-year-old child has been voiding straw-colored urine 6 or 7 times a day.
An 8-year-old is continent during the day but is incontinent 2 times during the night. By the age of 5, children should be continent both during the day and the night.
A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first? Release a small amount of urine into the toilet. Void normally to empty the bladder. Clean each side of the urinary meatus with a separate wipe. Catch a sample of urine in the specimen container.
Clean each side of the urinary meatus with a separate wipe. A clean-catch specimen is collected in mid-stream. The nurse will first instruct to clean each side of the urinary meatus, release a small amount of urine, catch a sample, and then complete voiding.
Three days post-surgery for breast reconstruction, the nurse assesses that the client is ambulating several times daily. The health care provider has not yet written an order to discontinue the client's urinary catheter. What is the appropriate nursing action? Select all that apply. Contact the health care provider to ask for an order for catheter discontinuation. Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). Perform, or allow client to perform, perineal hygiene at least once daily. Ensure that the drainage bag is above the level of the bladder at all times. Discontinue to catheter and report this to the healthcare provider.
Contact the health care provider to ask for an order for catheter discontinuation. Perform, or allow client to perform, perineal hygiene at least once daily. Rationale-The nurse should advocate for catheter discontinuation to prevent catheter-associated urinary tract infections (CAUTI), and still perform or encourage the client to perform daily perineal care. Discontinuation of the catheter should not take place until the nurse has received and order
A female infant has voided for the first time. The nurse notes the urine is light pink tinged. What actions by the nurse are indicated? Document the finding as normal, recognizing that they have been caused by the withdrawal of maternal hormones. Document the findings as normal, recognizing that they have been caused by an accumulation of uric acid crystals. Document the abnormal finding and report it to the charge nurse. Document the finding and report it to the attending physician.
Document the findings as normal, recognizing that they have been caused by an accumulation of uric acid crystals.
True/False-A fracture bedpan should be used only for clients who have fractures of the femur or lower spine.
False, fracture bedpan can be used for any client.
The nurse is caring for a client with a history of renal insufficiency and type 2 diabetes. Which prescription, if noted in the client's chart, would alert the nurse to discuss with the health care practitioner? Gentamicin 70 mg intramuscular (IM) every 8 hours Blueberry juice 10 oz by mouth (PO) daily Urine dipstick four times a day Encourage fluids intake - 2 to 3 L per day
Gentamicin 70 mg intramuscular (IM) every 8 hours Gentamicin is known to be nephrotoxic, so the nurse will check with the health care practitioner before administering it
A home care nurse visits a client diagnosed with depression who informs the nurse that he has been prescribed amitriptyline. What would the nurse include when educating the client about the effects of this medication? It causes urinary retention. It causes urine to turn blue-green. It decreases sensation of bladder fullness. It decreases glomerular filtrate rate.
It causes urine to turn blue-green.
The nurse is collecting a clean-catch specimen from a client. Which nursing action is performed correctly in this procedure? Don sterile gloves Collect the first 10 mL of urine voided in the sterile specimen container. Position the container near the meatus, and collect at least 10 mL of urine. Continue collecting the urine in the container until the bladder is empty
Position the container near the meatus, and collect at least 10 mL of urine.
A nurse is preparing to catheterize a female client with an overdistended bladder. Which action should the nurse take? Use a straight catheter. Insert one catheter to drain and another for continuous use. Prepare for a rush of a large amount of urine. Insert a larger catheter than indicated for long-term use.
Prepare for a rush of a large amount of urine. The nurse should prepare for a rush of a large amount of urine when the bladder has been distended. There is no need for more than one catheter. An indwelling catheter should be inserted for short-term use to prevent further distention.
A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true? The largest part of a regular bedpan should be placed under the client's buttocks. A regular bedpan is generally more comfortable for clients than a fracture bedpan. A fracture bedpan is preferred for urination and a regular bedpan is preferred for defecation. A fracture bedpan should be used only for clients who have fractures of the femur or lower spine.
The largest part of a regular bedpan should be placed under the client's buttocks.
The nurse mentor is observing a novice nurse preparing to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene if which action by the novice nurse is noted? The novice nurse asks the client to take a deep breath when resistance was met during insertion of the catheter. The novice nurse selects an 18 French Foley catheter to insert. The novice nurse places a trash receptacle within easy reach. The novice nurse assists the client to a dorsal recumbent position with knees flexed, feet about 2 ft (0.6 m) apart.
The novice nurse selects an 18 French Foley catheter to insert. A 14F to 16F catheter should be used when catheterizing an adult client. Size 18F can distend the urethra and cause more discomfort to the client during the procedure, as well as increase erosion of the bladder.
The nurse has received an order to remove a client's indwelling urinary catheter. Which actions are appropriate when carrying out this order? Select all that apply. The nurse may delegate this task to unlicensed assistive personnel (UAP). Strict aseptic technique must be used when removing the client's catheter. The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe. Limit the client's fluid intake for 2 to 4 hours prior to removal.
The nurse may delegate this task to a licensed practical/vocational nurse (LPN/LVN). The nurse should remove the water from the balloon by withdrawing it with a syringe.
which statements about suprapubic catheters is true? They are often preferred over an indwelling urethral catheter for long-term urinary drainage. They are surgically inserted through a small incision above the umbilicus. They drain urine directly from the ureters. Inadvertent dislodgement can permanently damage the urethra.
They are often preferred over an indwelling urethral catheter for long-term urinary drainage. Suprapubic catheters are associated with: decreased risk of contamination with organisms from fecal material; elimination of damage to the urethra; a higher rate of client satisfaction; and a lower risk of catheter-associated urinary tract infections.
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.
Tighten the internal muscles used to prevent or interrupt urination. Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen three to four times daily for 2 weeks to 1 month.
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? Stress incontinence Functional incontinence Total incontinence Overflow incontinence
Total incontinence Rationale-Total incontinence may be the result of surgery, trauma, or physical malformation; the client has continuous and unpredictable loss of urine. Functional incontinence occurs because the client is unable to reach the toilet.
first voiding newborn color is slightly pink-tinged. True/False
True- b/caused by uric acid crystals being excreted.
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate? cloudy, foul odor light yellow, clear clear, dark amber strongly aromatic, amber
cloudy, foul odor The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine.
During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care? condom catheter indwelling catheter intermittent catheterization at bedtime toileting the client every 2 hours
condom catheter
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
dark brown, cloudy Rationale-The client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine. Other answers are incorrect.
The nurse observes that a client frequently experiences urine loss when being transferred from a chair to the bed. Which type of incontinence does the nurse identify that the client is experiencing? urge total reflex functional
functional Rationale-Functional incontinence takes place when attempting to overcome obstacles, such as transferring from the wheelchair to the bed. Other types of incontinence have different causative factors.
A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours? functional incontinence transient incontinence stress incontinence reflex incontinence
functional incontinence Functional incontinence is urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, or loss of memory or disorientation.
