Fundamentals PrepU - Chapter 34: Urinary Elimination
The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. -Insert the lubricated catheter into the urethra. -Clean each labial fold, then the area directly over the meatus. -Discard used supplies. -Inflate the balloon with the correct amount of sterile saline. -Advance the catheter until there is a return of urine.
1 Clean each labial fold, then the area directly over the meatus. 2 Insert the lubricated catheter into the urethra. 3 Advance the catheter until there is a return of urine. 4 Inflate the balloon with the correct amount of sterile saline. 5 Discard used supplies.
A client reports an episode of losing control of urination when a bathroom was not close by. The client states, "I am worried this means that I am starting to lose control of my bladder." What is the appropriate nursing response? A) "Let's review your medication history and whether you consume bladder irritants." B) "I agree; please make an appointment with your health care provider." C) "I suggest that you invest in incontinence undergarments." D) "This only happened one time, so it's nothing to worry about."
A) "Let's review your medication history and whether you consume bladder irritants." Explanation: Urge incontinence can be aggravated by bladder irritants, such as caffeine or alcohol, and can take place if diuretics are taken in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the health care provider or to recommend incontinence undergarments.
A female client is asked to provide a specimen for a routine urinalysis. Which instructions should the nurse give the client? A) "Urinate directly into the specimen container." B) "Urinate into the sterile specimen container.after cleaning your labia." C) "Urinate a bit directly into the specimen container then cleanse the labia and continue to fill the container." D) "Urinate into the toilet first and then fill the container midstream."
A) "Urinate directly into the specimen container." Explanation: The nurse should ask the client to void into a clean bedpan, urinal, or receptacle (e.g. a specimen hat in the toilet bowl). Collecting a clean-catch or midstream urine specimen would require proper cleansing of the genital, as well as voiding a small amount of urine into the toilet and then catch the specimen midstream, in a sterile container.
Which is true regarding the normal urination? A) Catheterized clients should drain a minimum of 30 mL of urine per hour. B) Urinary output does not vary all that much between adults and children. C) In adults, the amount of urine voided typically does not depend on fluid intake and losses. D) In adults, the average amount of urine per void is 500 mL.
A) Catheterized clients should drain a minimum of 30 mL of urine per hour. Explanation: Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.
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. A) Contact the health care provider to ask for an order for catheter discontinuation. B)Discontinue to catheter and report this to the healthcare provider. C) Delegate catheter discontinuation to the Unlicensed Assistive Personnel (UAP). D) Ensure that the drainage bag is above the level of the bladder at all times. E) Perform, or allow client to perform, perineal hygiene at least once daily.
A) Contact the health care provider to ask for an order for catheter discontinuation. E) Perform, or allow client to perform, perineal hygiene at least once daily. Explanation: 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, and delegation should take place only if appropriate based on the UAP's qualification and the nurse's ongoing appropriate supervision. The drainage bag should never remain above the level of the bladder.
A nurse has catheterized a client to obtain urine for measuring postvoid residual (PVR) amount. The nurse obtains 40 mL of urine. What should the nurse do next? A) Document this normal finding for postvoid residual. B) Perform another catheterization to verify the amount. C) Report this abnormal finding to the health care provider. D) Palpate the abdomen for a distended bladder.
A) Document this normal finding for postvoid residual. Explanation: A postvoid residual (PVR) urine measures the amount of urine remaining in the bladder after voiding. It can be measured by catheterization or a bladder scan. A PVR of less than 50 mL indicates adequate bladder emptying. The nurse would document this normal finding for PVR. It is not necessary to palpate the abdomen as the bladder is empty.
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter? A) Fasten the condom securely enough to prevent leakage without constricting blood flow. B) Ensure the tip of the tubing is touching the tip of the client's penis. C) Remove the catheter every 8 hours, or more often in humid weather. D) Wipe the penis thoroughly with an alcohol swab and dry thoroughly before application.
A) Fasten the condom securely enough to prevent leakage without constricting blood flow. Explanation: Nursing care of a client with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1 to 2 in. (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area.
A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? Select all that apply. A) Neuromuscular problems may interfere with voluntary control of urination. B) Diminished ability of kidneys to concentrate urine may result in nocturia. C) Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. D) Altered thought processes may cause urinary frequency. E) Increased bladder motility decreases the incidence of urinary tract infections. F) Decreased bladder contractility may lead to urine retention and stasis.
A) Neuromuscular problems may interfere with voluntary control of urination. B) Diminished ability of kidneys to concentrate urine may result in nocturia. C) Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. D) Altered thought processes may cause urinary frequency. F) Decreased bladder contractility may lead to urine retention and stasis. Explanation: The effects of aging include the following: diminished ability of kidneys to concentrate urine, which may result in nocturia; decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination; decreased bladder contractility may lead to urine retention and stasis with increased risk of urinary tract infection; neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control of urination.
Which is not true of urine color? A) The appearance of urine streaked with blood is always abnormal. B) The color of urine ranges from light yellow to amber. C) Someone's state of hydration affects the color. D) Medications can alter urine's color.
A) The appearance of urine streaked with blood is always abnormal. Explanation: Urine may appear cloudy, dark reddish-brown, or streaked with blood when a woman is menstruating.
The nurse is choosing a collection device to collect urine from a nonambulatory male client. What would be the nurse's best choice? A) Urinal B) Bedpan C) Specimen hat D) Large urine collection bag
A) Urinal Explanation: A urinal is the best choice to collect urine from a nonambulatory male client. If the client is on strict bed rest or confined to bed due to weakness or disability. the client must be positioned in bed in as close to an upright position as feasible. In most instances, the client is able to place and hold the urinal himself. If he is unable to do so, the nurse should hold the urinal in place while the client urinates or place the urinal and leave the client alone for a few moments. A bedpan is not the best choice for a male client who tend to prefer the bottle-like shape of the urinal, although female clients tend to prefer the shape of a bedpan. A specimen hat is for a commode. A large urine collection bag would be used with an indwelling catheter.
An older adult resident of a long-term care facility has to get up and void several times during the night. This can be the result of what physiologic change with normal aging? A) diminished ability of the kidneys to concentrate urine B) increased bladder muscle tone causing urinary frequency C) increased bladder contractility causing urinary stasis D) decreased intake of fluids during daytime hours
A) diminished ability of the kidneys to concentrate urine Explanation: Physiologic changes that accompany normal aging may affect urination in older adults. These changes include the diminished ability of the kidneys to concentrate urine, which may result in nocturia (voiding during the night). Aging does not result in increased bladder muscle tone or increased bladder contractility. A decrease in fluid intake would not result in nocturia.
While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. What would the nurse document as an abnormal finding? A) reddened meatal skin B) moist perineal skin C) absence of discharge D) presence of smegma
A) reddened meatal skin Explanation: The presence of reddened meatal skin is an abnormal finding. The healthy skin should be moist and noninflamed with no discharge present. Smegma, an accumulation of white, odorous secretions from sebaceous glands found under the labia minora in women and under the foreskin in men, is normal and is not a discharge from the urinary meatus.
A nurse at a health care facility provides continence training to a client. During the training, the nurse plans a trial schedule for voiding that correlates with the time when the client is usually incontinent. What is a possible reason for the nurse's action? A) reduces potential for unintentional voiding B) ensures adequate urine volume C) prevents self-defeating consequences D) reveals the client's type of incontinence
A) reduces potential for unintentional voiding
The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would be preferred? A) the first voiding of the day B) the sample collected immediately after lunch C) the bedtime voiding D) the voiding collected at 4 p.m.
A) the first voiding of the day Explanation: The nurse would collect the first void of the day. The first urine voided in the morning is ordinarily more concentrated because the client usually consumes no fluids during the night and the effects of diet and activity are minimized. These factors make the first-voided specimen most likely to reveal any abnormalities.
A client with urinary incontinence is prescribed incontinence briefs. Which factors should be included in the client education the nurse provides? A) "Use the restroom upon waking and at bedtime to reduce the incidence of incontinence." B) "Cleanse the skin each time you change the briefs." C) "Spray perfume or cologne in the briefs before using." D) "Bathe at least twice per week."
B) "Cleanse the skin each time you change the briefs." Explanation: Clients need to change the protective pads or briefs frequently to avoid odor and to prevent skin irritation from prolonged exposure to moisture. Clients should not use cologne or perfume to mask odor, as it may irritate the perineal area. Clients wearing absorbent products should bathe at least daily. Each time the product is changed, the perineal area should be cleansed and examined for any areas of irritation. To reduce the incidence of incontinence, the client should use the bathroom at least every 2 hours during waking hours.
Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education? A) "At home, I take my water pill in the morning so that I don't have to use the bathroom as much during the night." B) "I make sure to limit how much I drink so that I don't have accidents." C) "I know it's hard to get there, but I want to try to use the commode instead of wearing an adult diaper." D) "I've made a point of scheduling when I drink water instead of waiting until I'm thirsty."
B) "I make sure to limit how much I drink so that I don't have accidents." Explanation: Limiting fluid intake is not a healthy practice, and clients should be encouraged not to use fluid restriction as an incontinence management strategy. Promoting fluid intake is beneficial for most clients who do not possess a contraindication, and it is appropriate and useful to take diuretics in the morning to avoid nocturia. Even though it may involve work for both the client and the nurse, clients who want to use a bathroom or commode rather than an adult absorbent brief should be encouraged to do so.
When caring for a client at the health care facility, the nurse has to record the client's urinary volume. Which amount would indicate a normal urinary volume? A) 200 mL/day B) 2,000 mL/day C) 3,500 mL/day D) 350 mL/day
B) 2,000 mL/day Explanation: A urinary volume of 2,000 mL/day is considered normal. A client's urination volume is normal if it is between 500 and 3,000 mL/day and considered average at 1,200 mL/day. Urination volume is considered abnormal if it is less than 400 mL/day or greater than 3,000 mL/day.
A nurse is examining the urine specimen of a dehydrated client. What is a characteristic odor of the urine voided by a dehydrated client? A) pungent B) strong C) aromatic D) foul
B) strong Explanation: Urine voided by a dehydrated client has a strong odor. A normal urine specimen has a faintly aromatic odor. A client with a urinary tract infection would have foul-smelling urine. Certain foods could contribute to the pungent odor of urine in a normal client.
Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? A) clean-catch specimen B) 24-hour specimen C) random specimen D) intermittent specimen
B) 24-hour specimen Explanation: A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.
When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action? A) Explain the procedure to the client. B) Check health record for provider's order. C) Gather equipment and supplies. D) Assess urine characteristics.
B) Check health record for provider's order. Explanation: The nurse will first check for an order to irrigate the Foley catheter. The other steps can be taken after the order is confirmed.
A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first? A) Release a small amount of urine into the toilet. B) Clean each side of the urinary meatus with a separate wipe. C) Catch a sample of urine in the specimen container. D) Void normally to empty the bladder.
B) Clean each side of the urinary meatus with a separate wipe. Explanation: 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.
A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take? A) Monitor vital signs B) Contact the health care provider C) Encourage fluids D) Instruct on proper wiping technique
B) Contact the health care provider Explanation: The term pyuria refers to the presence of pus in the urine. The nurse should first contact the health care provider, as antibiotic therapy may be necessary. Encouraging fluids, instruction on wiping technique and monitoring vital signs will follow.
The UAP reports that a client on furosemide has voided 4000 mL in a 24-hour period. What is the appropriate nursing action? A) Document the finding as normal. B) Contact the health care provider to decrease furosemide. C) Administer an additional dose of furosemide. D) Increase IV fluids.
B) Contact the health care provider to decrease furosemide. Explanation: Voiding over 3000 mL/day is considered abnormal. The client may benefit from a reduction in the amount of furosemide that is prescribed. Therefore, it is appropriate to contact the health care provider to decrease furosemide. Documenting the finding as normal, increasing IV fluids, and administering an additional dose of furosemide are not appropriate nursing actions.
A nurse collects a clean-catch specimen from a client at a health care facility. Which statement describes a clean-catch urine sample? A) a sample of urine collected in a sterile environment B) a sample of urine that is considered sterile C) a sample of urine collected over a period of 24 hours D) a sample of fresh urine collected in a clean container
B) a sample of urine that is considered sterile Explanation: A clean-catch specimen is a sample of urine that is considered sterile. A clean-catch specimen is preferred to a randomly voided specimen. This method of collection is preferred when a urine specimen is needed during a client's menstrual cycle. A void specimen is a sample of fresh urine collected in a clean container. A catheter specimen is a sample of urine collected in a sterile environment using a catheter. A 24-hour specimen is a sample of urine collected over a 24-hour period.
The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should: A) stop, deflate the balloon, withdraw the catheter 0.75 to 1.5 in (2 to 4 cm), and slowly reinflate. B) deflate the balloon, insert the catheter further, and slowly attempt reinflation. C) wait for 30 seconds, help the client to relax, and attempt inflation again. D) deflate the balloon, withdraw the catheter, and use a smaller sized catheter.
B) deflate the balloon, insert the catheter further, and slowly attempt reinflation. Explanation: If the client reports pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the client's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 0.5 to 1 in (1.25 to 2.5 cm), and slowly attempt to inflate the balloon again. Re-attempting inflation in the same location or after slight withdrawal could cause trauma to the client's urethra. It is not necessary to utilize a smaller gauge catheter.
The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing: A) nocturia. B) oliguria. C) polyuria. D) anuria.
B) oliguria. Explanation: Oliguria is a significant decrease in urine production. Anuria is an absence or near-absence of urine output. Nocturia is nighttime awakening to void. Polyuria is greatly increased urine production.
Which term is most closely associated with an acute urinary tract infection? A) proteinuria B) pyuria C) glycosuria D) anuria
B) pyuria Explanation: Pyuria, or the presence of pus in urine, is highly suggestive of a urinary tract infection (UTI). UTIs do not typically result in glycosuria (sugar in the urine) or proteinuria (protein in the urine). Similarly, a complete cessation of urine production (anuria) is not associated with uncomplicated UTI.
A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing? A) urge incontinence B) stress incontinence C) reflex incontinence D) functional incontinence
B) stress incontinence Explanation: The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to giving birth. Reflex incontinence is caused by damage to motor and sensory tracts in the lower spinal cord secondary to trauma. Urge incontinence is caused by bladder irritation secondary to infection. Functional incontinence is caused by impaired mobility, impaired cognition, or an inability to communicate.
A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate? A) total B) reflect C) urge D) stress
D) stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Other types of incontinence have different causative factors.
The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate? A) cloudy, foul odor B) strongly aromatic, dark amber C) light yellow, clear D) clear, colorless
B) strongly aromatic, dark amber Explanation: The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine. The other characteristics are not associated with dehydration.
Upon admission, the client informs the nurse of the medications he takes daily at home. When the nurse learns that the client takes amitriptyline, she anticipates the client's urine may have which discoloration?
Blue-green Explanation: The antidepressant amitriptyline or B-complex vitamins can turn urine green or blue-green. Anticoagulants may cause blood in the urine (pink or red color). Phenazopyridine, a urinary analgesic, can cause orange or orange-red urine. Levodopa, an antiparkinsonian drug, and injectable iron compounds can lead to brown or black urine.
A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem? A) "Don't worry, this is a normal condition for older adults." B) "Let me refer you to a urologist who can help you." C) "Let's explore structuring activities and toileting breaks." D) "It would be best just to get some adult diapers."
C) "Let's explore structuring activities and toileting breaks." Explanation: The nurse will promote the client's self-esteem by exploring ways in which the client can verbalize feelings, maintain dignity, and become empowered to participate in self-care. Telling the client to get adult undergarments (referring to these as "diapers" is not therapeutic), sending her to a urologist, and telling her not to worry discounts the client's concern.
A client has not voided for 8 hours after surgery. Which finding indicates the client has a distended bladder? A) A bulge over the costovertebral region of the flank B) A bulge in the left lower quadrant of the abdomen C) A bulge between the symphysis pubis and the umbilicus D) A bulge between ribs 11 and 12 and the umbilicus
C) A bulge between the symphysis pubis and the umbilicus Explanation: When the bladder is distended with urine, it rises above the symphysis pubis and may reach to just below the umbilicus. The other choices are anatomically incorrect for assessing a distended bladder.
The nurse has been closely monitoring a client who has recently had their indwelling urinary catheter removed. In the 6 hours since the catheter was removed, the client has yet to void. How should the nurse first respond to this assessment finding? A) Obtain an order for an oral diuretic and administer this drug to the client. B) Inform the health care provider and request blood work to assess the client's renal function. C) Assess the client's bladder by palpation and bedside ultrasound. D) Reinsert the client's urinary catheter.
C) Assess the client's bladder by palpation and bedside ultrasound. Explanation: The nurse should adhere to the nursing process, with assessment preceding interventions (such as reinserting the client's catheter), even if a standing order exists to reinsert the catheter if needed. Similarly, a diuretic would not be the first course of action. A short-term lack of urine output, especially following the removal of a catheter, is not indicative of renal failure.
A client reports having to void frequently, burning on urination, and odorous urine. Which action will the nurse take to prevent future urinary tract infections (UTIs)? A) Direct the client to wear tight pants which can help to keep out bacteria. B) Instruct the client to wipe back toward the front after urination. C) Encourage the client urinate after sexual intercourse. D) Restrict fluids before bedtime.
C) Encourage the client urinate after sexual intercourse. Explanation: A UTI can be caused by inadequate fluid intake; contamination from endogenous bacteria after sexual intercourse or defecation; delayed urination; tight, restrictive pants; and urinary calculi. The nurse will encourage the client to urinate after sexual intercourse.
A nurse caring for a client with a nephrostomy tube finds that the urine output from the tube has decreased and notterm-36ifies the health care provider. The health care provider writes an order for the tube to be irrigated. Which would be most appropriate for the nurse to do when irrigating a nephrostomy tube? A) Clamp the nephrostomy tube. B) Instill 50 mL of solution. C) Irrigate with sterile saline. D) Use clean technique.
C) Irrigate with sterile saline. Explanation: The nurse should use sterile saline for irrigation, as tap water may damage the kidneys. Irrigation of a nephrostomy must be done using strict asepsis, not a clean technique, and no more than 10 mL of sterile saline should be instilled. It is important never to clamp a nephrostomy tube because doing so would cause the backup of urine that could result in renal damage.
A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client? A) Fluid restriction B) Encouraging the client to stay close to home C) Regular toileting routine D) Indwelling catheterization
C) Regular toileting routine Explanation: The nurse should document the client's condition as urinary incontinence. A toileting routine and verbal reminders, external catheters for men, absorbent products, and excellent skin care and hygiene are appropriate interventions. Indwelling catheterization and fluid restriction can lead to urinary tract infection. Encouraging the client to stay home may be isolating.
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? A) The diameter of the catheter is too large. B) The nurse failed to deflate the retention balloon after pretesting it for integrity. C) The client has an enlarged prostate. D) The client has an occult abscess in the urethra.
C) The client has an enlarged prostate. Explanation: Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.
A client is prescribed a diuretic for swelling of the lower extremities. What would the nurse teach the client about the effect of the medication on the client's urinary output? A) The client's urinary output will be decreased. B) The client's urine will be a medium-amber color. C) The client's urinary output will be increased. D) The client's urine will have a strong ammonia odor.
C) The client's urinary output will be increased. Explanation: If the diuretic is effective, the client will have an increase in urinary output, not a decrease in urinary output. Certain drugs cause the urine to change color. Diuretics can lighten the color of urine to pale yellow. The odor of the urine will not have a stronger ammonia odor than usual.
The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include? A) Keep muscles contracted for at least 30 seconds. B) Perform these exercises 10 times daily for 1 month. C) Tighten the internal muscles used to prevent or interrupt urination. D) Relax muscles for at least 1 minute between contractions.
C) Tighten the internal muscles used to prevent or interrupt urination. Explanation: 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 client should not be instructed to keep muscles contracted for at least 30 seconds, relax muscles for at least 1 minute between exercises, nor perform these exercises 10 times daily for 1 month.
Which of the following describes the term micturition? A) catheterizing the bladder B) collecting a urine specimen C) emptying the bladder D) experiencing total incontinence
C) emptying the bladder Explanation: The process of emptying the bladder is known as urination, micturition, or voiding. Catheterizing the bladder is when a urinary catheter is placed inside the urethra. Collecting a urine specimen can be by clean catch or by use of a urinary catheter. Incontinence is when a client voids on oneself.
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample? A) evening B) before bedtime C) first thing in the morning D) afternoon
C) first thing in the morning Explanation: While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance? A) retention catheter B) indwelling urethral catheter C) intermittent urethral catheter D) Foley catheter
C) intermittent urethral catheter Explanation: An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted.
A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra? A) straight catheter B) indwelling urethral catheter C) suprapubic catheter D) intermittent urethral catheter
C) suprapubic catheter Explanation: A suprapubic catheter is used for long-term continuous drainage and is inserted through a small incision above the pubic area. Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or abdominal surgery has compromised the flow of urine through the urethra. An indwelling urethral catheter, straight, and intermittent urethral catheter is placed in the urethra.
A nurse is providing education to a client who is scheduled for a cystoscopy as an outpatient procedure. Which description would the nurse include when discussing this procedure? A) a three-dimensional image of the urinary tract B) a specialized x-ray to assess kidney size and shape C) use of a flexible tube that is guided into the bladder D) use of instruments to measure pressure and urine flow
C) use of a flexible tube that is guided into the bladder Explanation: Cystoscopy involves insertion of a tube into the bladder for the purpose of direct visualization. A cystoscope is a flexible tube that can be inserted into the urethra and guided into the bladder. A light at the end of the cystoscope allows the health care provider to look for abnormalities such as tumors, stones, or structural problems. Magnetic resonance imaging is a three- dimensional view of the urinary structures. Computed tomography is a specialized x-ray to assess kidney size and shape. Urodynamic studies involve measuring pressure and urine flow.
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? A) "The client will be placed in a reclining position with knees bent." B) "I will place a bath blanket over the client to provide privacy." C) "Washing hands before and after the procedure is important." D) "I will use clean gloves to handle the catheter and other equipment."
D) "I will use clean gloves to handle the catheter and other equipment." Explanation: Sterile gloves are required for catheterization. Other answers demonstrate competency and do not require further intervention by the experienced nurse.
A client has just returned from surgery with a Foley catheter in place. The nurse anticipates that the catheter will be removed within what time frame after the operation? A) 72 hours B) 48 hours C) 36 hours D) 24 hours
D) 24 hours Explanation: The longer an indwelling catheter remains in the bladder, the greater the chance of health care-associated infection (HAI). The CDC recommends removal of indwelling catheters within 24 hours postoperatively whenever possible.
A home care client has an indwelling catheter connected to a leg bag. What can the nurse recommend to help prevent development of a urinary tract infection? A) Take the tubing apart and wash it each day. B) Restrict intake of fluids to decrease amount of urine. C) Always wipe from front to back after voiding. D) Empty the leg bag at regular intervals.
D) Empty the leg bag at regular intervals. Explanation: Clients with indwelling catheters are at risk for the development of a urinary tract infection. A full drainage bag may cause reflux of urine into the bladder, increasing the risk of a urinary tract infection.
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data? A) urinary retention B) nocturia C) oliguria D) anuria
D) anuria Explanation: Absence of urine for a 24-hour period reflects anuria.
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? A) light yellow, clear B) clear, dark amber C) strongly aromatic, amber D) cloudy, foul odor
D) cloudy, foul odor Explanation: The nurse anticipates that the client has an infection, which is characterized by cloudy, foul-smelling urine. Urine is normally light yellow and clear. Dark amber urine that is strongly aromatic could indicate dehydration, but would not create the symptoms noted.
A client is admitted to the health care facility reporting pain on urination that is secondary to a urinary tract infection (UTI). The nurse documents this finding as: A) polyuria B) nocturia C) hematuria D) dysuria
D) dysuria Explanation: Dysuria means painful voiding. Pain is often associated with UTIs and is felt as a burning sensation during urination. Polyuria is the formation and excretion of excessive amounts of urine in the absence of a concurrent increase in fluid intake. Voiding during normal sleeping hours is called nocturia. Hematuria refers to blood in the urine.
A nurse is caring for a client who is being treated for bladder infection. The client reports having difficulty voiding and feeling uncomfortable. How should the nurse document the client's condition? A) anuria B) oliguria C) polyuria D) dysuria
D) dysuria Explanation: The nurse could document the client's condition as dysuria, which is difficulty or discomfort when voiding. Dysuria is a common symptom of trauma to the urethra or bladder infection. Anuria means absence of urine or a volume of 100 mL or less in 24 hours. Oliguria indicates inadequate elimination of urine. Polyuria is the term used to indicate greater than normal urinary volume, and may accompany minor dietary variations.
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? A) reflex B) total C) urge D) functional
D) functional Explanation: 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.
Which term is most closely associated with an acute urinary tract infection? A) proteinuria B) glycosuria C) anuria D) pyuria
D) pyuria Explanation: Pyuria, or the presence of pus in urine, is highly suggestive of a urinary tract infection (UTI). UTIs do not typically result in glycosuria (sugar in the urine) or proteinuria (protein in the urine). Similarly, a complete cessation of urine production (anuria) is not associated with uncomplicated UTI.
A client reports to the nurse that after delivering an infant, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? A) urge B) total C) reflex D) stress
D) stress Explanation: Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.
A client tells the nurse, "Every time I sneeze, I wet my pants." What is this type of involuntary escape of urine called? A) urinary incompetence B) uncontrolled voiding C) normal micturition D) urinary incontinence
D) urinary incontinence Explanation: The process of emptying the bladder is termed micturition, voiding, or urination. Sometimes increased abdominal pressure, such as occurs when sneezing or coughing, forces an involuntary escape of urine, especially in women because the urethra is shorter. Any involuntary loss of urine that causes such a problem is referred to as urinary incontinence. Urge incontinence is uncontrolled urine leakage or voiding (of moderate to large volume) that occurs immediately after an urgent, irrepressible need to void.
A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection? A) Begin the collection at a specific time. B) Void and discard the urine. C) Add the first voiding to the specimen. D) Keep the urine warm during collection.
Void and discard the urine. Explanation: The collection is initiated at a specific time, but the client is asked to void at that time and discard the urine from the first voiding. In most instances, a preservative is added to the collection bottle, the collected urine is kept cold through refrigeration, or it is kept on ice.