Ch. 31

A nurse is teaching the patient about how to perform Kegel exercises. Which patient statement indicates that additional teaching is needed?

"I will do them while I urinate."

A nurse has performed a bladder scan on a patient to check for residual urine. Which information should be documented in the patient's chart? Select all that apply.

1. Amount of residual noted 2. How patient tolerated procedure 4. Whether or not abdomen is distended

A nurse needs to acquire a clean-catch midstream urine specimen from a female patient. The patient is capable of getting the specimen without assistance after the nurse provides instructions. Which instructions should the nurse provide? Select all that apply.

1. Place the open specimen container upright on a flat surface. 2. Hold labia open during cleaning and until the specimen is acquired. 5. Collect a specimen of urine by placing the cup in the urinary stream.

A nurse is performing a urine dipstick test. Which actions should the nurse include in this skill? Select all that apply.

2. Check expiration date on bottle. 3. Remove one strip from bottle.

A nurse has obtained a clean-catch specimen from a patient. Which findings indicate a potential problem as it relates to the urinary system? Select all that apply.

2. Cloudy appearance 4. Sediment present 5. Dark amber color

A health-care provider (HCP) has ordered a 24-hour unit collection for a patient. Which steps should the nurse include in the plan of care? Select all that apply.

3. Collect all urine during the 24-hour period with the exception of the first void. 4. Document the exact date and time that the 24-hour period is started. 5. Keep all urine collected in a labeled specimen container.

A nurse is reviewing information reported by a 58-year-old patient about urinary patterns. The patient reports frequent voiding during the night up to 3 times. What is the best nursing action?

Ask about daily fluid intake patterns.

A nurse monitoring a patient with an indwelling catheter finds minimal urine in the drainage bag and no urine in the tubing. What is the next action that the nurse should take?

Check tubing alignment.

A patient has surgery that creates a pouch from his intestine. The ureters empty into the pouch, while a nipple valve allows him to perform self-catheterization to intermittently empty the pouch. Which type of urinary diversion would the nurse identify?

Continent urostomy

A patient had an indwelling urinary catheter removed after a postoperative cholecystectomy 4 hours ago and has not voided. What is the next action the nurse should take?

Continue to monitor.

A patient arrives in the emergency department (ED) stating the inability to empty the bladder for the past 3 days. An ultrasound reveals an extremely distended bladder, and the health-care provider (HCP) orders immediate placement of an indwelling urinary catheter. Which possible complication would the nurse associate with the urgency of the order?

Development of hydronephrosis

A nurse is caring for a patient with a kidney infection. Output is tallied at the end of the shift, and the nurse notes that the patient has voided 240 mL in the past 8 hours. Which action should the nurse take next?

Document the output amount.

A nurse is working with an unlicensed assistive personnel (UAP) during the shift who is monitoring intake and output for assigned patients. Which action of the UAP if observed by the nurse indicates immediate action?

Empties drainage bags only at end of shift

A home health nurse (HHN) is visiting a patient who performs self-catheterization. The HHN observes the patient's technique as a plan to decrease the possibility of urinary tract infection (UTI). Which observation of the patient's technique should the nurse correct?

Patient puts on clean gloves without washing hands.

A nurse is providing care for multiple patients in the hospital who are ordered on intake and output (I&O) measurement. Which patient would the nurse anticipate will need extra assistance in obtaining accurate data?

Patient who is vomiting with an intake of only ice chips

An LPN/LVN is working in a long-term care facility. A patient is having difficulty managing urinary continence, and the LPN/LVN begins a program of bladder training with the patient. Which part of the bladder training program should the LPN/LVN reconsider?

Provide the patient's favorite beverages, which are coffee and iced tea.

A nurse receives a report on a patient who just returned from surgery after a transurethral prostatectomy (TURP). The nurse is told that the patient has a three-way urinary catheter. The nurse would associate the catheter selection based on which patient need?

Provides continuous bladder irrigation to control clot formation

A nurse has collected a urinary specimen from a new patient admitted to the hospital. Which finding indicates a potential abnormality?

Sediment present

A nurse is working with a family whose 10-year-old daughter has recently had two urinary tract infections (UTIs). Which instructions should the nurse discuss with the patient and her family?

Showering is recommended.

A nurse is reviewing the results of a patient's urinalysis. Which finding indicates adequate urinary function?

Specific gravity 1.010

A patient with recurrent urinary tract infections (UTIs) has been admitted to the hospital for treatment. Which type of therapy in addition to antibiotics would the nurse anticipate that the health-care provider (HCP) will order?

Tylenol

A nurse is monitoring a cardiac patient who is receiving furosemide therapy via oral route. Which finding indicates an increased likelihood that the medication is not effective?

Urine output 100 mL in 8 hours

A 92-year-old female patient is admitted to the emergency department (ED) for observation related to chest pain. The patient has to void. What is the best nursing response?

Use PureWick system.

A nurse is providing care to a patient who had a right arthroplasty and is 3 days postoperative. The patient has to void but is tired from frequent ambulation during the shift. What is the best nursing action?

Use a fracture pan.

A nurse is caring for a patient with an indwelling catheter and notes that urine is leaking. What is the best nursing action?

Verify amount of fluid instilled in catheter.