104 Chapter 46: Urinary Elimination

4. A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output.

ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological or psychological condition exists.

19. When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection? a. Bacteria b. Casts c. Crystals d. Protein

ANS: A Bacteria indicate a urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal alterations. Protein is not visible under a microscope and indicates renal disease.

28. A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence? a. "Drink your nightly glass of milk earlier in the evening." b. "Set your alarm clock to wake you every 2 hours, so you can get up to void." c. "Line your bedding with plastic sheets to protect your mattress." d. "Empty your bladder completely before going to bed."

ANS: A Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination, but will not affect urine produced throughout the night from late-night fluid intake.

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6.4 d. Protein level of 2 mg/100 mL

ANS: A Normal glomerular filtration rate should be around 125 mL/min; a severe decrease in renal perfusion could indicate a life-threatening problem such as shock or dehydration. Normal urine output is 1000 to 2000 mL/day; an output of 30 mL/hr or less for 2 or more hours would be cause for concern. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease.

14. A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper.

ANS: A Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail. DIF: Analyze REF: 1056 OBJ: Identify nursing diagnoses appropriate for patients with alterations in urinary elimination.

38. Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective? a. Recording an output that is larger than the amount instilled b. Presence of blood clots or sediment in the drainage bag c. Reduction in discomfort from bladder distention d. Visualizing clear urinary catheter tubing

ANS: A Recording an output that is greater than what was irrigated into the bladder shows progress that the bladder is draining urine. The other observations do not objectively measure the increase in urine output.

21. What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine? a. Fever and chills b. Difficulty holding in urine c. Increased blood pressure d. Abnormal blood sugar

ANS: A The presence of white blood cells in urine indicates a urinary tract infection. Difficulty with urinary elimination indicates blockage or renal damage. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine, as this finding indicates diabetes.

10. Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?"

ANS: A To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, changing urination patterns, and losing urine during coughing or sneezing focus on specific pathological conditions.

39. The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient? a. A 12-year-old female with severe abdominal trauma b. A 24-year-old male with severe genital warts around the urethra c. A 50-year-old male with recent prostatectomy d. A 75-year-old female with end-stage renal disease

ANS: A Urinary diversion would be needed in a patient with abdominal trauma who might have injury to the urinary system. Genital warts are not needed for urinary diversion. Patients with a prostatectomy may require intermittent catheterization after the procedure. End-stage renal disease would not be affected by rerouting the flow of urine.

26. A nurse anticipates urodynamic testing for a patient with which symptom? a. Involuntary urine leakage b. Severe flank pain c. Presence of blood in urine d. Dysuria

ANS: A Urodynamic testing evaluates the muscle function of the bladder and is used to look for the cause of urinary incontinence. Severe flank pain indicates renal calculi; CT scan or IVP would be a more efficient diagnostic test. Blood indicates trauma to the urethral or bladder mucosa. Pain on elimination may warrant cultures to check for infection.

37. To reduce patient discomfort during closed catheter irrigation, the nurse should a. Use room temperature irrigation solution. b. Administer the solution as quickly as possible. c. Allow the solution to sit in the bladder for at least 1 hour. d. Raise the bag of irrigation solution at least 12 inches above the bladder.

ANS: A Using cold solutions, instilling solutions too quickly, and prolonging filling of the bladder can cause discomfort and cramping. To reduce this, ensure that the solution is at room temperature, lower the solution bag so it instills slowly, and drain the bladder fully after an ordered amount of time.

2. The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.) a. Asking the patient to void and to discard the first sample. b. Keeping the urine collection container on ice. c. Withholding all patient medications for the day. d. Asking the patient to notify the staff before and after every void.

ANS: A, B When obtaining a 24-hour urine specimen, it is important to keep the urine in cool condition. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution.

3. Which of the following are indications for irrigating a urinary catheter? (Select all that apply.) a. Sediment occluding within the tubing b. Blood clots in the bladder following surgery c. Rupture of the catheter balloon d. Bladder infection e. Presence of renal calculi

ANS: A, B, D Catheter irrigation is used to flush and remove blockage that may be impeding the catheter from properly draining the bladder. Irrigation is used to remove blood clots in the bladder following surgery. For patients with bladder infection, an antibiotic irrigation is often ordered. A ruptured catheter balloon will involve extensive follow-up and possible surgery to remove the particles. Renal calculi obstruct the ureters and therefore the flow of urine before it reaches the bladder.

9. When caring for a patient with urinary retention, the nurse would anticipate an order for a. Limited fluid intake. b. A urinary catheter. c. Diuretic medication. d. A renal angiogram.

ANS: B A urinary catheter would relieve urinary retention. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. A renal angiogram is an inappropriate diagnostic test for urinary retention.

29. Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they a. Are embarrassed that they will urinate on the bedding. b. Would feel more comfortable assuming a normal voiding position. c. Feel they are losing their independence by asking the nursing staff to help. d. Are worried about acquiring a urinary tract infection.

ANS: B Assuming a normal voiding position helps patients relax and be able to void; lying in bed is not the typical position in which people void. Men usually are most comfortable when standing; women are more comfortable when sitting and squatting. Embarrassment at using the bedpan and worrying about a urinary tract infection are not related to the lying-in-bed position. Fear of loss of independence is not related to use of the bedpan or urinal.

6. The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures. C. Perineal care is often neglected by nursing staff. D.Bedpans and urinals are not stored properly and transmit infection.

ANS: B E. coli is the leading pathogen causing UTIs; this pathogen enters during procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the greatest cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently. Bedpans and urinals are not inserted into the urinary tract, so they are unlikely to be the primary cause of UTI.

34. When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection? a. Inserting the catheter using strict clean technique b. Performing hand hygiene before and after providing perineal care c. Fully inflating the catheter's balloon according to the manufacturer's recommendation d. Disconnecting and replacing the catheter drainage bag once per shift

ANS: B Hand hygiene helps prevent infection in patients with a urinary catheter. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgement and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection. DIF: Apply REF: 1048 OBJ: Discuss nursing measures

13. Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence

ANS: B Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow's hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self-esteem. Decreased mobility can lead to self-care deficit; the nurse's priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene.

11. Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins

ANS: B The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin.

27. A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first? a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient's progress b. Utilizing the power of suggestion by turning on the faucet and letting the water run c. Obtaining an order for a Foley catheter d. Administering diuretic medication

ANS: B To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.

If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra

ANS: B Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur.

33. The nurse would question an order to insert a urinary catheter on which patient? a. A 26-year-old patient with a recent spinal cord injury at T2 b. A 30-year-old patient requiring drug screening for employment c. A 40-year-old patient undergoing bladder repair surgery d. An 86-year-old patient requiring monitoring of urinary output for renal failure

ANS: B Urinary catheterization places the patient at increased risk for infection and should be performed only when necessary. Urine can be obtained via clean-catch technique for a drug screening or urinalysis. Spinal cord injury, surgery, and renal failure wi h critical t intake and output monitoring are all appropriate reasons for catheterization.

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI.

ANS: B Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection.

5. The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient's blood? (Select all that apply.) a. Gravity b. Osmosis c. Diffusion d. Filtration

ANS: B, C Osmosis and diffusion are the two processes used to clean the patient's blood in both types of dialysis. In peritoneal dialysis, osmosis and dialysis occur across the semi-permeable peritoneal membrane. In hemodialysis, osmosis and dialysis occur through the filter membrane on the artificial kidney. In peritoneal dialysis, the dialysate flows by gravity out of the abdomen.Gravity has no effect on cleansing of the blood. Filtration is the process that occurs in the glomerulus as blood flows through the kidney.

4. Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.) a. Fever b. Nausea and vomiting c. Headache d. Altered mental status e. Dysuria

ANS: B, C, D Uremic syndrome is associated with end-stage renal disease. Signs and symptoms include headache, altered mental status, coma, seizures, nausea, vomiting, and pericarditis.

1. Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.) a. Growing urine cultures for up to 12 hours b. Labeling all specimens with date, time, and initials c. Wearing gown, gloves, and mask for all specimen handling d. Allowing the patient adequate time and privacy to void e. Squeezing urine from diapers into a urine specimen cup f. Transporting specimens to the laboratory in a timely fashion g. Placing a plastic bag over the child's urethra to catch urine

ANS: B, D, F, G All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Children may have difficulty voiding; attaching a plastic bag gives the child more time and freedom to void. Urine cultures can take up to 48 hours to develop. Gown, gloves, and mask are not necessary for specimen handling unless otherwise indicated. Urine should not be squeezed from diapers.

30. The nurse would anticipate inserting a Coudé catheter for which patient? a. An 8-year-old male undergoing anesthesia for a tonsillectomy b. A 24-year-old female who is going into labor c. A 56-year-old male admitted for bladder irrigation d. An 86-year-old female admitted for a urinary tract infection.

ANS: C A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.

15. The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom? a. Dysuria b. Flank pain c. Frequency d. Fever and chills

ANS: C Cystitis is inflammation of the bladder; associated symptoms include hematuria and urgency/frequency. Dysuria is a commo n symptom of a lower urinary tract infection. Flank pain, fever, and chills are all signs of pyelonephritis.

32. A nurse notifies the provider immediately if a patient with an indwelling catheter a. Complains of discomfort upon insertion of the catheter. b. Places the drainage bag higher than the waist while ambulating. c. Has not collected any urine in the drainage bag for 2 hours. d. Is incontinent of stool and contaminates the external portion of the catheter.

ANS: C If the patient has not produced urine in 2 hours, the physician needs to be notified immediately because this could indicate renal failure. Discomfort upon catheter insertion is unpleasant but unavoidable. The nurse is responsible for maintaining the integrity of the catheter by ensuring that the drainage bag is below the patient's bladder. Stool left on the catheter can cause infection and should be removed as soon as it is noticed. The nurse should ensure that frequent perineal care is being provided.

20. The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be a. Cloudy. b. Discolored. c. Sweet smelling. d. Painful.

ANS: C Incomplete fat metabolism and buildup of ketones give urine a sweet or fruity odor. Cloudy urine may indicate infection or renal failure. Discolored urine may result from various medications. Painful urination indicates an alteration in urinary elimination.

24. Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching? a. "I'm allergic to shrimp, so I should monitor myself for an allergic reaction." b. "I will complete my bowel prep program the night before the scan." c. "I will be anesthetized so that I lie perfectly still during the procedure." d. "I will ask the technician to play music to ease my anxiety."

ANS: C Patients are not put under anesthesia for a CT scan; instead the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT. Bowel cleansing is often performed before CT. Listening to music will help the patient relax and remain still during the examination.

31. The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection? a. Emptying the drainage bag every 8 hours or when half full b. Kinking the catheter tubing to obtain a urine specimen c. Placing the drainage bag on the side rail of the patient's bed d. Failing to secure the catheter tubing to the patient's thigh

ANS: C Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. The drainage bag should be emptied and output recorded every 8 hours or when needed. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient's thigh places the patient at risk for tissue injury from catheter dislodgment.

8. A patient has fallen several times in the past week when attempting to get to the bathroom. The patient informs the nurse that he gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem? a. Clear the path to the bathroom of all obstacles before bed. b. Leave the bathroom light on to illuminate a pathway. c. Limit fluid and caffeine intake before bed. d. Practice Kegel exercises to strengthen bladder muscles.

ANS: C Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. Clearing a path to the restroom or illuminating the path, or shortening the distance to the restroom, may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing incontinence.

36. A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding? a. "Since I'm taking medication, I do not need to worry about proper hygiene." b. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out." c. "My medication may discolor my urine; this should resolve once the medication is stopped." d. "I should not have sexual intercourse until the infection has resolved."

ANS: C Some anti-infective medications turn urine colors; this is normal and will dissipate as the medication leaves the system. Even if the patient is on medication, hygiene is important to prevent spread or reinfection. Fluid intake should be increased to help flush out bacteria; however, 15 to 20 glasses is too much. Sexual intercourse is allowed with a urinary tract infection, as long as good hygiene and safe practices are used.

5. The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom.

ANS: C Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother.

16. Which assessment question should the nurse ask if stress incontinence is suspected? a. "Does your bladder feel distended?" b. "Do you empty your bladder completely when you void?" c. "Do you experience urine leakage when you cough or sneeze?" d. "Do your symptoms increase with consumption of alcohol or caffeine?"

ANS: C Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence.

A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order for diuretics.

ANS: C The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be

18. To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to a. Cleanse the urethral meatus from the area of most contamination to least. b. Initiate the first part of the urine stream directly into the collection cup. c. Hold the labia apart while voiding into the specimen cup. d. Drink fluids 5 minutes before collecting the urine specimen.

ANS: C The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front-to-back). The initial steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.

7. An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient's plan of care? a. Urinary retention b. Hesitancy c. Urgency d. Urinary incontinence

ANS: D Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine known as Urinary incontinence. Urinary retention is the inability to empty the bladder. Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of the need to void immediately.

25. The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by a. Obtaining baseline vital signs after the start of the procedure. b. Monitoring the extremity for neurocirculatory function. c. Keeping the patient on bed rest for the prescribed time. d. Administering an antihistamine medication to the patient.

ANS: D Before the procedure is begun, the nurse should assess the patient for food and other allergies and should administer an antihistamine, because a contrast iodine-based dye is used for the procedure. Baseline vitals should be obtained before the start of the procedure and frequently thereafter. The procedure site is monitored and the patient kept on bed rest after the procedure is complete.

35. An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate? a. Urinary tract infections are unavoidable in the elderly because of a weakened immune system. b. Decreasing fluid intake will decrease the amount of urine with bacteria produced. c. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection. d. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

ANS: D Cranberry juice and other acidic foods decrease adherence of bacteria to the bladder wall. Urinary tract infections are avoidable in the elderly population with proper knowledge and hygiene. Perineal skin should be cleansed from front to back to avoid spreading fecal matter to the urethra. Increasing fluids will help to flush bacteria, thus preventing them from residing in the bladder for prolonged periods of time.

22. The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis? a. Renal ultrasound b. Bladder scan c. KUB x-ray d. Intravenous pyelogram

ANS: D Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.

23. A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse's first priority in caring for this patient? a. Turn the patient on the right side to alleviate pressure on the left kidney. b. Encourage the patient to increase fluid intake to flush the obstruction. c. Administer narcotic medications to alleviate pain. d. Monitor the patient for fever, rash, and difficulty breathing.

ANS: D Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Many individuals are allergic to shellfish; therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety.

17. When establishing a diagnosis of altered urinary elimination, the nurse should first a. Establish normal voiding patterns for the patient. b. Encourage the patient to flush kidneys by drinking excessive fluids. c. Monitor patients' voiding attempts by assisting them with every attempt. d. Discuss causes and solutions to problems related to micturition.

ANS: D The nurse should assess first to determine cause, then should discuss and create goals with the patient, so nurse and patient can work in tandem to normalize voiding. The nurse should incorporate the patient's input into creating a plan of care for the patient. Drinking excessive fluid will not help and may worsen alterations in urinary elimination. The nurse does not need to monitor every void attempt by the patient; instead the nurse should provide patient education. The nurse asks the patient about normal voiding patterns, but establishing voiding patterns is a later intervention.

Which statement best illustrates the nurse's understanding of the role of nursing assistive personnel (NAP) when inserting an indwelling urinary catheter in a female patient? a. "Please direct the light to better illuminate the patient's perineal area." b. "You need to be comfortable inserting a catheter in a patient of her size." c. "See if a size 14-French catheter is big enough." d. "Find out if the patient has any allergies to latex or iodine."

a"Please direct the light to better illuminate the patient's perineal area." CORRECT. This is the correct answer. No aspect of the skill of indwelling urinary catheter insertion may be delegated to NAP, but the nurse may delegate related tasks, such as redirecting the lighting during the procedure.

Which action(s) would minimize the patient's risk for injury during insertion of an indwelling urinary catheter? a. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances b. Thoroughly cleansing the patient's perineal area with povidone-iodine solution before inserting the catheter c. Performing proper hand hygiene and applying gloves before inserting the catheter d. Terminating the insertion if the patient reports pain at any time during the procedure

a. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances CORRECT. This is the correct answer. Serious allergic reactions may occur if the patient has an allergy to latex, antiseptic, tape, or iodine-based cleanse

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time? a. Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. b. Withdraw the catheter to 1 inch, and ask the patient to cough. c. Encourage the patient to cough as the catheter is advanced. d. Apply pressure to the patient's lower abdomen over the bladder.

a. Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. CORRECT. This is the correct option, because the urethra may be longer than 3 to 4 inches.

A patient with a suprapubic catheter is complaining of pain. What will the nurse do first to help this patient? a. Ensure that the patient is not lying on the drainage tubing b. Instruct the patient to increase his or her oral fluid intake c. Observe the rate of drainage in the urine collection bag d. Notify the health care provider

a. Ensure that the patient is not lying on the drainage tubing CORRECT. The nurse will first ensure that the patient is not lying on the drainage tubing, since doing so could obstruct urine flow and cause pain.

During intermittent open bladder irrigation, a patient complains of pain. Which action would the nurse take first? a. Examine the drainage tubing for clots, sediment, and kinks. b. Notify the health care provider. c. Leave the irrigation drip wide open. d. Monitor the patient's vital signs.

a. Examine the drainage tubing for clots, sediment, and kinks. CORRECT. This is the correct answer. If the patient complained of pain during intermittent open bladder irrigation, the nurse would first examine the drainage tubing for clots, sediment, and kinks.

Which measure may be taken to minimize the staff's risk for infection from a urine specimen? a. Firmly securing the lid of the urine specimen container b. Using a sterile urine specimen container c. Using a sterile syringe to access the sampling port d. Placing the urine specimen container in the refrigerator until the laboratory comes to get it

a. Firmly securing the lid of the urine specimen container CORRECT. Securing the specimen container lid is one way to minimize the risk for infection to the staff.

which action would the nurse take to manage continuous urinary catheter irrigation for a patient whose urine is bright red and contains clots? a. Increase the irrigation drip rate. b. Notify the patient's health care provider of the blood and clots in the urine. c. Encourage the patient to increase fluid intake. d. Apply ice to the patient's lower abdominal area.

a. Increase the irrigation drip rate. CORRECT. This is the correct answer. The nurse would increase the irrigation drip rate to flush the urinary tract until the urine was only tinged pink with blood.

The nurse has completed an intermittent straight urinary catheterization of a female patient. Which action would the nurse delegate to nursing assistive personnel (NAP)? a. Measure and empty the urine. b. Palpate the abdomen. c. Ask the patient if she has any pain. d. Document the procedure.

a. Measure and empty the urine. CORRECT. The NAP can measure and empty the urine collection tray after an intermittent straight catheterization.

Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter? a. The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. b. A registered nurse, not NAP, must remove the catheter. c. Catheter removal must be executed within 10 minutes of beginning the procedure. d. Catheter removal must take place within 5 days of catheter insertion.

a. The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique. CORRECT. Using clean technique is the best way to minimize the risk of introducing pathogens to the patient's urinary trac

Which statement might the nurse make to nursing assistive personnel (NAP) assigned to care for a patient with an established suprapubic catheter? a. "Tell me if the catheter site looks inflamed." b. "I need to know the patient's temperature each time it's taken." c. "Wear sterile treatment gloves when you remove the dressing." d. "Let me know if the patient's catheter is infected"

b. "I need to know the patient's temperature each time it's taken." CORRECT. Temperature measurement can be delegated to NAP. This statement is appropriate for the nurse to make.

Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had an indwelling urinary catheter removed? a. "Teach the patient the signs of a urinary tract infection." b. "Tell me when and how much the patient first voids." c. "Explain that voiding might be uncomfortable for 4 to 5 days." d. "Assess the patient for a distended bladder before the end of the shift."

b. "Tell me when and how much the patient first voids." CORRECT. The nurse may delegate to NAP the task of reporting the time and amount of the patient's first voiding after removal of an indwelling urinary catheter.

Which is not an expected outcome on a first voiding after catheter removal? a. Mild burning b. Fever and back pain c. Producing only a small amount of urine d. Discomfort

b. Fever and back pain CORRECT. The nurse would instruct the patient to report signs of a urinary tract infection, such as fever and back pain. These signs are unlikely to be present during the patient's first voiding after catheter removal.

Which action will ensure that a sterile urine specimen is handled properly in order to help obtain reliable results? a. Placing the specimen in a biohazard bag b. Having someone take the specimen to the lab immediately c. Cleaning the outside surface of the container d. Ensuring that a stock of sterile urine collection kits is available

b. Having someone take the specimen to the lab immediately CORRECT. Having someone take the specimen to the lab immediately will help to ensure reliable results. The specimen must be delivered to the lab within 20 minutes of collection.

While performing an intermittent straight urinary catheterization of a female patient, the nurse inadvertently inserts the catheter into the patient's vagina. Which action would the nurse take next? a. Remove the catheter, and rinse it thoroughly in sterile water for reuse. b. Keep the catheter in place, and begin again with a new sterile catheter. c. Remove the catheter, relubricate it, and insert it into the urinary meatus. d. Stop advancing the catheter, and notify the health care provider.

b. Keep the catheter in place, and begin again with a new sterile catheter. CORRECT. This action is correct. If a straight catheter is inadvertently inserted into the vagina, it should be left in place as a landmark, and the nurse must begin the catheterization process again with a new sterile catheter

Which observation indicates that instruction given to nursing assistive personnel (NAP) in caring for a patient with an indwelling urinary catheter has been effective? a. The collection bag has been placed on the side rail of the bed. b. The excess catheter tubing has been coiled beside the patient's inner thigh. c. The collection bag has been placed on the bed. d. The collection bag is held above the level of the bladder while ambulating the patient.

b. The excess catheter tubing has been coiled beside the patient's inner thigh. ambulating the patient. CORRECT. The excess drainage tubing should be coiled next to the patient's inner thigh, to facilitate urine flow.

When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse would offer patient education regarding which common complication? a. Urinary incontinence b. Urinary tract infection c. Adequate oral hydration d. Kidney stones

b. Urinary tract infection CORRECT. A urinary tract infection may develop 2 to 3 days after indwelling urinary catheter removal, and the nurse would educate the patient to be alert for signs and symptoms of such an infection.

Which action would the nurse take to minimize a patient's risk for injury during urinary catheter irrigation? a. Change the tubing every 8 hours. b. Use slow, even pressure when injecting the irrigating fluid. c. Adhere to aseptic technique during the irrigation process. d. Monitor the patient's temperature every 4 hours.

b. Use slow, even pressure when injecting the irrigating fluid. CORRECT. This is the correct answer. Using slow, even pressure during the instillation of fluid into the bladder helps avert bladder trauma.

3. Which instruction might the nurse give to nursing assistive personnel (NAP) helping to care for a patient receiving bladder irrigation? a. "Tell me how he tolerates the irrigation." b. "Be sure to check for signs of a urinary tract infection." c. "Measure and report the patient's temperature to me every 4 hours." d. "Ask the patient about pain level."

c. "Measure and report the patient's temperature to me every 4 hours." CORRECT. This is the correct answer. Measuring and reporting temperature is a skill that may be delegated to NAP

When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to ensure that sufficient urine is collected? a. Checking the patency of the indwelling catheter tubing b. Placing the urinary collection bag below the level of the bladder c. Clamping the catheter tubing for 15 minutes before collection d. Asking the patient to drink a glass of water 30 minutes before the collection

c. Clamping the catheter tubing for 15 minutes before collection CORRECT. Clamping the catheter tubing for 15 minutes before collection will ensure that sufficient urine is available for the specimen.

Which action will the nurse implement to reduce the risk of catheter-associated urinary tract infection (CAUTI) in a male patient with an indwelling urinary catheter? a. Frequently pull on the drainage system tubing. b. Use the largest-size catheter possible. c. Clean the urinary meatus daily. d. Apply antiseptics to the urinary meatus.

c. Clean the urinary meatus daily. Apply antiseptics to the urinary meatus. CORRECT. To reduce the risk of CAUTI, daily cleansing of the urinary meatus is necessary.

A newly inserted suprapubic catheter becomes dislodged. What action should the nurse perform first? a. Notify the health care provider b. Apply pressure over the site c. Cover the site with a sterile dressing d. Help the patient into a side-lying position

c. Cover the site with a sterile dressing CORRECT. When a newly inserted suprapubic catheter becomes dislodged, the nurse's first action is to cover the site with a sterile dressing.

When preparing to insert an indwelling urinary catheter in a male patient, it is important for the nurse to do what? a. Remove the cotton balls from the kit for later use. b. Advance the catheter 10 to 12 inches or until urine flows. c. Lubricate the first 5 to 7 inches of the catheter. d. Hold the penis at a 45-degree angle during insertion.

c. Lubricate the first 5 to 7 inches of the catheter CORRECT. The first 5 to 7 inches of the catheter is lubricated to ease insertion.

The nurse has completed the initial inspection of the patient's perineum and is preparing to insert an indwelling urinary catheter. Which action would the nurse complete next? a. Begin to establish a sterile field. b. Open and assemble the urine drainage bag. c. Remove soiled gloves, and perform hand hygiene. d. Center the drape over the patient's labia.

c. Remove soiled gloves, and perform hand hygiene. CORRECT. This is the correct answer. The nurse's soiled gloves must be removed prior to setting up the sterile field.

While setting up the sterile field in preparation for inserting an indwelling urinary catheter, a male patient is incontinent of urine over most of the supplies. What action would the nurse take to reduce the patient's risk for infection? a. Rinse off the supplies that were contaminated with urine. b. Cleanse the patient's urinary meatus. c. Replace all contaminated supplies, and begin the process again. d. Change the patient's bed linens.

c. Replace all contaminated supplies, and begin the process again. CORRECT. If the sterile field is contaminated while preparing to insert an indwelling urinary catheter, all contaminated supplies must be replaced and the process begun again.

A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells the nurse that she "doesn't feel comfortable in this position" and that her "back really hurts." What is the nurse's best response? a. Reassure the patient that the procedure will take only a few minutes. b. Promise to reposition the patient as soon as the catheter has been inserted. c. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. d. Explain to the patient that the position will allow the catheter insertion to be more efficient.

c. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip. CORRECT. This is the correct answer. The side-lying (Sims') position is an acceptable alternative that may be more comfortable for the patient.

Which nursing action reduces the risk of injury in a patient with a suprapubic catheter? a. Applying sterile gloves before cleaning the catheter insertion site b. Cleansing the skin surrounding the insertion site c. Securing the catheter to the abdomen d. Keeping the drainage bag above the level of the patient's bladder

c. Securing the catheter to the abdomen CORRECT. Securing the catheter to the abdomen will reduce the risk of injury to the patient by ensuring that excess tension is not applied to the catheter. Such tension could damage the bladder

What is the primary reason the nurse applies sterile gloves rather than clean ones when caring for a patient with a newly inserted suprapubic catheter? a. To protect the nurse and other patients from pathogens b. To collect a sterile urine sample c. To reduce the patient's risk of infection d. To reduce the patient's risk of injury

c. To reduce the patient's risk of infection CORRECT. This is the correct answer. When providing care for a newly inserted suprapubic catheter, the nurse wears sterile gloves to reduce the risk of infecting the wound at the catheter insertion site.

Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a patient with an indwelling urinary catheter? a. Wear clean gloves when inserting the catheter. b. Inflate the balloon on the catheter before using it. c. Use the smallest-size catheter possible. d. Empty the urine by disconnecting the catheter from the collection bag.

c. Use the smallest-size catheter possible. CORRECT. This is the correct answer. To reduce the risk of CAUTI in a patient with an indwelling urinary catheter, the nurse would use the smallest-size catheter possible.

The nurse instructs nursing assistive personnel (NAP) regarding proper technique for intermittent straight catheterization of a male patient. Which statement made by NAP indicates that the instruction was effective? a. "I'll help you set up the sterile field." b. "I'll get a sterile urine cup for you." c. "There are leg straps in the utility room." d. "I'll help keep his legs away from the sterile field."

d. "I'll help keep his legs away from the sterile field." CORRECT. NAP can assist with intermittent straight catheterization by helping with patient positioning and comfort

Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter? a. Using a 5-mL syringe to deflate the balloon b. Using sterile scissors to cut the valve to deflate the balloon c. Tugging gently on the catheter to pull the balloon through the urethra d. Checking the documentation for the volume of fluid used to inflate the balloon

d. Checking the documentation for the volume of fluid used to inflate the balloon CORRECT. Checking the volume of fluid used to inflate the balloon in order to ensure the balloon is completely deflated before removal is the nursing action that will minimize a patient's risk for injury during removal of an indwelling urinary catheter.

Which action is most important in reducing the risk for infection in a patient receiving open intermittent irrigation of a urinary catheter? a. Attaching the urinary drainage bag to the bed frame b. Inspecting the drainage tubing for kinks c. Disposing of contaminated items after the procedure d. Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter

d. Cleaning the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter CORRECT. This is the correct answer. Swabbing the end of the drainage tubing with an antiseptic wipe before reconnecting it to the catheter reduces the number of pathogens that migrate from the tubing directly into the bladder.

Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary catheter? a. Sterile technique protects the patient from microorganisms in the urine. b. Sterile technique protects the nurse from microorganisms in the urine. c. Sterile technique reduces the amount of pain caused by the procedure. d. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination.

d. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the result of contamination. CORRECT. The nurse will use sterile technique to obtain a urine specimen from an indwelling urinary catheter to ensure that any microorganisms in the specimen are from the urine, not from the patient's skin, the nurse's hands, or the environment.

What is the best reason for the nurse to instruct a male patient to take slow, deep breaths during insertion of an indwelling urinary catheter? a. To increase oxygenation b. To reduce blood pressure c. To distract him d. To promote relaxation

d. To promote relaxation CORRECT. The nurse would instruct a male patient to take slow, deep breaths during catheter insertion if the nurse felt resistance to the advancing catheter or if the patient reported pain. Deep breathing promotes relaxation, which might help to pass the catheter through the urinary sphincter.

Why does the nurse cleanse a female patient's perineum before inserting an intermittent urinary catheter? a. To encourage the bladder to drain fully b. To encourage spontaneous voiding c. To prevent bowel elimination during the procedure d. To reduce the patient's risk of urinary tract infection

d. To reduce the patient's risk of urinary tract infection CORRECT. The nurse cleanses a female patient's perineum before inserting an intermittent urinary catheter in order to reduce the patient's risk of infection

Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the collection of a routine urine sample from a patient with an indwelling urinary catheter? a. "Does the patient understand why the specimen is needed and why we cannot obtain it from the Foley bag?" b. "See if the catheter is causing the patient any problems and if he is having any pain." c. "Please get two sterile urine collection containers from the utility room." d. "Let me know if the urine contains blood or sediment, or appears cloudy."

d. "Let me know if the urine contains blood or sediment, or appears cloudy." CORRECT. This statement correctly focuses on the characteristics of urine that an NAP must report to the nurse.