Chapter 28: Nursing Management: Patients With Urinary Disorders

The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?

Coffee in the morning Explanation: The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.

Which of the following accounts for the majority of ureteral injuries?

Crashes, falls, and assaults Explanation: Gunshot wounds account for 95% of ureteral injuries, which may range from contusions to complete transection. Unintentional injury to the ureter may occur during gynecologic or urologic surgery. Knife wounds and sports injuries do not account for the majority of ureteral injuries.

The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following?

Peritonitis Explanation: Clinical manifestations of peritonitis include abdominal pain and distention, absence of bowel sounds, nausea and vomiting, fever, changes in vital signs.

A nurse is presenting at a community health promotion fair that is focused on disease prevention and screening. A middle-aged participant has brought up an article that she recently read about bladder cancer and has asked the nurse about prevention measures. How should the nurse respond to this woman's inquiry?

"If you smoke cigarettes, quitting will greatly reduce your risk of bladder cancer." Explanation: Cigarette smoking exceeds the significance of family history, fluid intake, and diet in the etiology of bladder cancer.

Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply. -Urinary retention -Deficient knowledge: management of urinary diversion -Disturbed body image -Risk for impaired skin integrity -Chronic pain

-Deficient knowledge: management of urinary diversion -Disturbed body image -Risk for impaired skin integrity Explanation: Deficient knowledge, disturbed body image, and risk for impaired skin integrity are expected problems for the client with a new ileal conduit. Urinary retention and chronic pain are not expected client problems.

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program?

Assessing present voiding patterns Explanation: The guidelines for initiating bladder retraining include assessing the client's present intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment.

A 69-year-old man is postoperative day 2 following a transurethral prostatic resection (TUPR). The patient had his urinary catheter removed at 06:00 this morning but has not voided in the 5 hours since the removal, despite the fact that he has been drinking large amounts of fluids. What nursing assessment will most accurately determine whether the patient is retaining urine?

Bladder ultrasound Explanation: Bladder ultrasound provides an accurate reading of a patient's current bladder volume. Palpation and inspection are also relevant assessments, but these are less accurate. Analysis of intake and output can be informative, but this does not include the important variable of urine production.

A nurse is conducting a health history on a patient who is seeing her health care provider for symptoms consistent with a UTI. The nurse understands that the most common route of infection is which of the following?

By ascending infection (transurethral) Explanation: The most common route of infection is transurethral, in which bacteria colonize the periurethral area and enter the bladder by means of the urethra.

The nurse is teaching a client how to perform self-catheterization. Which direction should the nurse include?

Catheterization should occur every 4 to 6 hours and before bedtime. Explanation: The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. The catheter is rinsed with tap water after soaking in a cleaning solution. Either antibacterial soap or povidone-iodine solution is recommended for cleaning urinary catheters at home. The nurse uses sterile technique in the hospital setting.

After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?

Decreased pelvic muscle tone due to multiple pregnancies Explanation: Stress incontinence is due to decreased pelvic muscle tone, which is associated with multiple pregnancies, obstetric injuries, obesity, menopause, or pelvic disease. Transient incontinence is due to increased urine production related to metabolic conditions. Urge incontinence is due to bladder irritation related to urinary tract infections, bladder tumors, radiation therapy, enlarged prostate, or neurologic dysfunction. Overflow incontinence is due to obstruction from fecal impaction or enlarged prostate.

A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following?

Diabetes mellitus Explanation: Increased urinary glucose levels create an infection-prone environment in the urinary tract.

Which instruction would be included in a teaching plan for a client diagnosed with a urinary tract infection?

Drink liberal amount of fluids. Explanation: Clients diagnosed with a UTI should drink liberal amounts of fluids. They should void every 2 to 3 hours. Coffee and tea are urinary irritants. The client should shower instead of bathe in a tub because bacteria in the bathwater may enter the urethra.

Which of the following would be least appropriate to suggest to a client with a urinary diversion to control odor?

Eat plenty of cheese and eggs. Explanation: To help control odor, the client should use pouches with carbon filters or other odor barriers or add a few drops of liquid deodorizer or diluted white vinegar to the pouch. Foods such as cranberry juice, yogurt or buttermilk may help to decrease odor while foods such as asparagus, cheese, and eggs may impart an odor to the urine.

The nurse is conducting a community education program on UTIs. The nurse determines that the participants understand the teaching when they identify which factor is contributing to UTIs in older adults?

Immunocompromise Explanation: Factors that contribute to UTIs in older adults include immunocompromise, cognitive impairment, high incidence of chronic illness, immobility, incomplete emptying of the bladder, obstructed flow of urine, and frequent use of antimicrobial agents.

A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region that radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site?

Kidney Explanation: The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation.

The nurse is caring for a patient who underwent percutaneous lithotripsy earlier in the day. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. What instruction should the nurse give the patient?

Notify the health care provider about cloudy or foul-smelling urine. Explanation: The patient should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the patient should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal due to residual stone products. Hematuria is common after lithotripsy.

A 49-year-old man has been brought to the emergency department by his wife, who states that her husband is experiencing a repeat episode of kidneys stones. When planning interventions for this patient's immediate care, what problem is likely to be the priority?

Pain Explanation: Urinary stones are typically accompanied by severe pain, the treatment of which would be a nursing priority. Decreased LOC and cardiac output are unlikely. Fluid and electrolyte imbalances may occur, but not likely in the short term.

The following catheterization procedures are used to treat clients with urinary retention. Which procedure would the nurse identify as carrying the greatest risk to the client?

Permanent drainage with a urethral catheter Explanation: Permanent drainage with a urethral catheter carries the greatest risk. It may also increase the risk for bladder stones, renal diseases, bladder infections, and urosepsis, a severe systemic infection by microorganisms in the urinary tract invading the bloodstream. Clean intermittent catheterization has the fewest complications and is the preferred treatment for urinary retention. The Credé voiding procedure is used in the case of clients who have lost control over their nervous systems, secondary to injury or disease.

Which medication may be ordered to relieve discomfort associated with a UTI?

Phenazopyridine Explanation: Phenazopyridine is a urinary analgesic ordered to relieve discomfort associated with UTIs. Nitrofurantoin, ciprofloxacin, and levofloxacin are antibiotics.

Which medication may be ordered to relieve discomfort associated with a urinary tract infection?

Phenazopyridine Explanation: Phenazopyridine is a urinary analgesic ordered to relieve discomfort associated with a UTI. Nitrofurantoin, ciprofloxacin, and levofloxacin are antibiotics.

An 82-year-old client experiences urinary incontinence. Which factor should the nurse assess before beginning a bladder training program for this client?

Physical and environmental conditions Explanation: It is essential to assess the client's physical and environmental conditions before beginning a bladder training program, because the client may not be able to reach the bathroom in time. During the bladder training program, a change in environment may be an effective suggestion for the client. It is not so essential to assess the client's history of allergy, occupation, and smoking habits before beginning a bladder training program.

The nurse is preparing to assess a client's new stoma. Which finding would the nurse include in the documentation of a healthy stoma?

Pink color Explanation: Characteristics of a healthy stoma include a pink and moist appearance. It is insensitive to pain because it has no nerve endings. A black, purple, or brown color may indicate that the vascular supply may be compromised, which may require surgical intervention.

Which characteristic is seen with a healthy stoma?

Pink color Explanation: Characteristics of a normal stoma include a pink and moist appearance. It is insensitive to pain because it has no nerve endings. The area is vascular and may bleed when cleaned.

Which term refers to inflammation of the renal pelvis?

Pyelonephritis Explanation: Pyelonephritis is an upper urinary tract inflammation, which may be acute or chronic. Cystitis is inflammation of the urinary bladder. Urethritis is inflammation of the urethra. Interstitial nephritis is inflammation of the kidney.

Sympathomimetics have which of the following effects on the body?

Relaxation of bladder wall Explanation: Sympathomimetics mimic the sympathetic nervous system, causing increased heart rate and contractility, dilation of bronchioles and pupils, and bladder wall relaxation.

A woman comes to her health care provider's office with signs and symptoms of kidney stones. Which of the following should be the primary medical management goal?

Relieve the pain. Explanation: The immediate objective is to relieve pain, which can be incapacitating depending on the location of the stone.

Which type of incontinence is the involuntary loss of urine through an intact urethra as a result of coughing?

Stress Explanation: Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sneezing, coughing, or changing position. Reflex incontinence is the involuntary loss of urine because of hyperreflexia in the absence of normal sensations usually associated with voiding. Urge incontinence is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder.

A patient had an ileal conduit created and is being cared for by a postsurgical nurse. What is a complication the nurse would monitor this patient for in the immediate postoperative care period?

Ureteral obstruction Explanation: Complications that may follow placement of an ileal conduit include wound infection or wound dehiscence, urinary leakage, ureteral obstruction, hyperchloremic acidosis, small bowel obstruction, ileus, and gangrene of the stoma. The other given problems are not likely complications.

The nurse advises a patient with renal stones to avoid eating shellfish, asparagus, and organ meats. She emphasizes these foods because she knows that his renal stones are composed of which of the following substances?

Uric acid Explanation: Uric acid stones are found in patients with gout and myeloproliferative disorders. Therefore, a diet low in purines is recommended.

A group of students are reviewing information about disorders of the bladder and urethra. The students demonstrate understanding of the material when they identify which of the following as a voiding dysfunction?

Urinary retention Explanation: Urinary retention and urinary incontinence are voiding dysfunctions, temporary or permanent alterations in the ability to urinate normally. Cystitis is an infectious disorder. Bladder stones and urethral stricture are obstructive disorders.

The nurse who teaches a client about preventing recurrent urinary tract infections would include which statement?

Void immediately after sexual intercourse. Explanation: Voiding flushes the urethra, expelling contaminants. Showers are encouraged, rather than tub baths, because bacteria in the bath water may enter the urethra. Coffee, tea, colas, alcohol, and other fluids that are urinary tract irritants should be avoided. The client should be encouraged to void every 2 to 3 hours during the day and completely empty the bladder.

The nurse is caring for several older clients. For which client would the nurse be especially alert for signs and symptoms of pyelonephritis?

A client with urinary obstruction Explanation: The client with urinary obstruction is at the highest risk of developing pyelonephritis because a urinary obstruction is the most common cause of pyelonephritis in older adults. Acute glomerulonephritis usually occurs in older adults with preexisting chronic glomerulonephritis. Older clients with acute renal failure or urinary tumor are not at high risk for developing pyelonephritis.

The patient has been diagnosed with urge incontinence. What classification of medication does the nurse expect the patient will be placed on to help alleviate the symptoms?

Anticholinergic agents Explanation: Anticholinergic agents inhibit bladder contraction and are considered first line medications for urge incontinence.

A client with urinary retention needs to undergo a procedure to insert an indwelling catheter. What should the nurse discuss with the health care provider before catheterization?

type and size of the catheter to be used Explanation: Before catheterization, the nurse should inquire about the type and size of the catheter to be used and if the catheter should be removed or retained in place after the bladder is empty.

A major goal when caring for a catheterized patient is to prevent infection. Select all the nursing actions that apply. -Empty the collection bag at least every 8 hours to reduce bacterial growth. -Disconnect the tubing to collect urine samples. -Suspend the drainage bag off the floor. -Wash the perineal area with soap and water at least twice daily. -Irrigate the catheter every 24 hours.

-Empty the collection bag at least every 8 hours to reduce bacterial growth. -Suspend the drainage bag off the floor. -Wash the perineal area with soap and water at least twice daily. Explanation: Never disconnect the tubing to collect samples, irrigate, or ambulate the patient since this will allow bacteria to enter the closed system. Drainage systems should have an aspiration or puncture port from which a specimen can be obtained. The drainage system should not be disconnected.

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?

Acute pain Explanation: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time.

A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom?

Painless hematuria Explanation: The most common first symptom of a malignant tumor of the bladder is painless hematuria. Additional early symptoms include UTI with symptoms such as fever, dysuria, urgency, and frequency. Later symptoms are related to metastases and include pelvic pain, urinary retention (if the tumor blocks the bladder outlet), and urinary frequency from the tumor occupying bladder space.

A nurse is assessing a client with suspected bladder cancer. Which finding would the nurse most likely expect to assess?

painless hematuria Explanation: Bladder tumors usually arise at the base of the bladder and involve the ureteral orifices and bladder neck. Painless gross hematuria is the most common symptom of bladder cancer. Infection of the urinary tract is a common complication, producing frequency, urgency, and dysuria. Any alteration in voiding or change in the urine may indicate cancer of the bladder. Pelvic or back pain may occur with metastasis.

The nurse is planning the care of a male patient who has been admitted to the medical unit with an exacerbation of chronic pyelonephritis. Which of the following goals should the nurse prioritize in the planning of this patient's nursing care?

The patient will consume 3 to 4 L of fluid each day. Explanation: High fluid intake is important in the treatment of chronic pyelonephritis. It is not necessary for the patient to discuss the pathophysiology of his disease, and it is unrealistic to expect baseline ADLs. The patient is likely to have an indwelling catheter, and scheduled voiding is not necessary, even in the absence of a catheter.

The clinic nurse is teaching a young woman about preventing recurrent urinary tract infections. What information should the nurse include?

Drink liberal amounts of fluids. Explanation: The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to increase urine production and flow, which flushes the bacteria from the urinary tract. Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely because this can significantly lower urine bacterial counts, reduce urinary stasis, and prevent reinfection. The patient should be encouraged to shower rather than bathe.

An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?

Application of an ostomy pouch Explanation: An ileal conduit involves care of a urinary stoma, much like that of a fecal stoma, including the application of an ostomy pouch, skin protection, and stoma care. Intermittent catheterizations and irrigations are appropriate for a continent urinary diverse such as a Kock or Indiana pouch. Exercises to promote sphincter control are appropriate for an ureterosigmoidoscopy.

The nurse has implemented a bladder retraining program with a 65-year-old woman after the removal of her indwelling urinary catheter. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient has 50 mL of urine remaining in her bladder after voiding. What would be the nurse's best response to this finding?

Avoid further interventions at this time, as this is an acceptable finding. Explanation: The residual urine amount is acceptable, and intervention is not required by the nurse. Retraining the bladder begins immediately after the indwelling catheter is removed. The patient is placed on a timed voiding schedule, usually every 2 to 3 hours and, at the given time intervals, is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner. If 100 mL or more of urine remains in the bladder, straight catheterization may be performed for complete bladder emptying.

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?

Low purine Explanation: A low-purine diet is used for uric acid stones, although the benefits are unknown. Clients with a history of calcium oxalate stone formation need a diet that is adequate in calcium and low in oxalate. Only clients who have type II absorptive hypercalciuria—approximately half of the clients—need to limit calcium intake. Usually, clients are told to increase their fluid intake significantly, consume a moderate protein intake, and limit sodium. Avoiding excessive protein intake is associated with lower urinary oxalate and lower uric acid levels. Reducing sodium intake can lower urinary calcium levels.

If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?

Perform meticulous perineal care daily with soap and water Explanation: Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used when inserting a urinary bladder catheter. The nurse must maintain a closed system and use the catheter's port to obtain specimens. The catheter bag must never be placed on the client's abdomen unless it is clamped because it may cause urine to flow back from the tubing into the bladder.

A 44-year-old woman was diagnosed with an uncomplicated urinary tract infection (UTI) and completed her prescribed 3-day course of antibiotics 2 days ago. However, she states that she is experiencing the same signs and symptoms that initially prompted her to seek care. The nurse should anticipate that:

The patient may require another short course of antibiotics followed by a longer-term regimen. Explanation: If infection recurs after completing antimicrobial therapy, another short course (3 to 4 days) of full-dose antimicrobial therapy followed by a regular bedtime dose of an antimicrobial agent may be prescribed. In addition, continuous prophylaxis via a 4- to 12-month course of antibiotics may be considered, either nightly or every other night. IV antibiotics are not likely necessary, and the infection may not be self-limiting.

A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate, I can't control it and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?

Urge Explanation: Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an over distended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect?

Urinary calculi Explanation: Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; however, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi. The pain is accompanied by renal or ureteral colic, painful spasms that attempt to move the stone. The pain comes in waves that radiate to the inguinal ring, the inner aspect of the thigh, and to the testicle or tip of the penis in men, or the urinary meatus or labia in women. Clients with acute glomerulonephritis may be asymptomatic or may exhibit fever, nausea, malaise, headache, edema (generalized or periorbital), pain, and mild to moderate hypertension. Clients with ureteral stricture may complain of flank pain and tenderness at the costovertebral angle and back or abdominal discomfort. A client with renal cell carcinoma rarely exhibits symptoms early on but may present with painless hematuria and persistent back pain in later stages.

A nurse is providing care for a patient who has had an indwelling urinary catheter in place for the past several days. To reduce this patient's risk of developing a catheter-related infection, the nurse should:

Ensure that the collection bag is always below the height of the patient's bladder. Explanation: The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Bacteria enter the urinary drainage bag, multiply rapidly, and then migrate to the drainage tubing, catheter, and bladder. By keeping the drainage bag lower than the patient's bladder and not allowing urine to flow back into the bladder, this risk is minimized. Clamping, frequent emptying, and disinfecting do not necessarily reduce the patient's risk of developing an infection.

A 52-year-old patient is scheduled to undergo ileal conduit surgery and has several appropriate questions for the nurse. What would be the most relevant nursing diagnosis for this patient?

Knowledge deficit about the surgical procedure and postoperative care Explanation: The most appropriate nursing diagnosis for this patient would be knowledge deficit about the surgical procedure and postoperative care. The fact that the patient has several appropriate questions best supports this diagnosis. Questions do not necessarily indicate fear, anxiety, or a self-care deficit.