Med Surg - Chapter 49
The nurse is caring for a client recently diagnosed with renal calculi. The nurse should instruct the client to increase fluid intake to a level where the client produces at least how much urine each day? A. 1,250 mL B. 2,000 mL C. 2,750 mL D. 3,500 mL
B. 2,000 mL Rationale: Unless contraindicated by kidney injury or hydronephrosis, clients with renal stones should drink at least eight 8-oz (250 mL) glasses of water daily or have IV fluids
A nurse on a busy medical unit provides care for many clients who require indwelling urinary catheters at some point during their hospital care. The nurse should recognize a heightened risk of injury associated with indwelling catheter use in which client? A. A client whose diagnosis of chronic kidney disease requires a fluid restriction B. A client who has Alzheimer disease and who is acutely agitated C. A client who is on bed rest following a recent episode of venous thromboembolism D. A client who has decreased mobility following a transmetatarsal amputation
B. A client who has Alzheimer disease and who is acutely agitated. Rationale: Clients who are confused and agitated risk trauma through the removal of an indwelling catheter which has the balloon still inflated. Recent VTE, amputation, and fluid restriction do not directly create a risk for injury or trauma associated with indwelling catheter use
The nurse has implemented a bladder retraining program for an older adult client. The nurse places the client on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the client typically has approximately 50 mL of urine remaining in the bladder after voiding. What would be the nurse's best response to this finding? A. Perform a straight catheterization on this client. B. Avoid further interventions at this time, as this is an acceptable finding. C. Place an indwelling urinary catheter. D. Press on the client's bladder in an attempt to encourage complete emptying.
B. Avoid further interventions at this time, as this is an acceptable finding. Rationale: In adults older than 60 years of age, 50 to 100 mL of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Consequently, further interventions are not likely warranted.
A 52-year-old client is scheduled to undergo ileal conduit surgery. When planning this client's discharge education, what is the most plausible nursing diagnosis that the nurse should address? A. Impaired mobility related to limitations posed by the ileal conduit B. Deficient knowledge related to care of the ileal conduit C. Risk for deficient fluid volume related to urinary diversion D. Risk for autonomic dysreflexia related to disruption of the sacral plexus
B. Deficient knowledge related to care of the ileal conduit. Rationale: The client will most likely require extensive teaching about the care and maintenance of a new urinary diversion. A diversion does not create a serious risk of fluid volume deficit. Mobility is unlikely to be impaired after the immediate postsurgical recovery. The sacral plexus is not threatened by the creation of a urinary diversion.
A client being treated in the hospital has been experiencing occasional urinary retention. What voiding trigger technique would help this client? A. Using a bedpan instead of a commode B. Dipping the client's hands in warm water C. Performing a bladder scan after voiding D. Encouraging male clients to use a urinal in bed
B. Dipping the client's hands in warm water. Rationale: Dipping the client's hands in warm water is a urinary trigger technique that helps encourage clients to start voiding. Other trigger techniques include turning on the faucet while the client is attempting to void and stroking the abdomen or inner thighs. Using a commode instead of a bedpan is a nursing measure to encourage normal voiding patterns. Encouraging a male client to use a urinal while standing is more natural and comfortable and is also linked to voiding patterns. Bladder scanning after voiding will assess whether the client is retaining urine but is not a trigger technique.
A client has undergone the creation of an Indiana pouch for the treatment of bladder cancer. The nurse identified the nursing diagnosis of "disturbed body image." How can the nurse best address the effects of this urinary diversion on the client's body image? A. Emphasize that the diversion is an integral part of successful cancer treatment. B. Encourage the client to speak openly and frankly about the diversion. C. Allow the client to initiate the process of providing care for the diversion. D. Provide the client with detailed written materials about the diversion at the time of discharge.
B. Encourage the client to speak openly and frankly about the diversion. Rationale: Allowing the client to express concerns and anxious feelings can help with body image, especially in adjusting to the changes in toileting habits. The nurse may have to initiate dialogue about the management of the diversion, especially if the client is hesitant. Provision of educational materials is rarely sufficient to address a sudden change and profound change in body image. Emphasizing the role of the diversion in cancer treatment does not directly address the client's body image.
Resection of a client's bladder tumor has been incomplete and the client is preparing for the administration of the first ordered instillation of topical chemotherapy. When preparing the client, the nurse should emphasize the need to do which of the following? A. Remain NPO for 12 hours prior to the treatment. B. Hold the solution in the bladder for 2 hours before voiding. C. Drink the intravesical solution quickly and on an empty stomach. D. Avoid acidic foods and beverages until the full cycle of treatment is complete.
B. Hold the solution in the bladder for 2 hours before voiding. Rationale: The client is allowed to eat and drink before the instillation procedure. Once the bladder is full, the client must retain the intravesical solution for 2 hours before voiding. The solution is instilled through the meatus; it is not consumed orally. There is no need to avoid acidic foods and beverages during treatment.
A client with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The client weighs 60 kg. The nurse is monitoring the client's urine output hourly and notifies the health care provider when the hourly output is less than what amount? A. 30 mL B. 50 mL C. 100 mL D. 125 mL
A. 30 mL Rationale: A urine output below 0.5 mL/kg/hr may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.
The nurse is assessing a client admitted with renal stones. During the admission assessment, what parameters should the nurse address? Select all that apply. A. Dietary history B. Family history of renal stones C. Medication history D. Surgical history E. Vaccination history
A. Dietary history B. Family history of renal stones C. Medication history Rationale: Dietary and medication histories and family history of renal stones are obtained to identify factors predisposing the client to stone formation. When caring for a client with renal stones, it would not normally be a priority to assess the vaccination history or surgical history, since these factors are not usually related to the etiology of kidney stones
A client is undergoing diagnostic testing for a suspected urinary obstruction. The nurse should know that incomplete emptying of the bladder due to bladder outlet obstruction can cause what issue? A. Hydronephrosis B. Nephritic syndrome C. Pyelonephritis D. Nephrotoxicity
A. Hydronephrosis Rationale: If voiding dysfunction goes undetected and untreated, the upper urinary system may become compromised. Chronic incomplete bladder emptying from poor detrusor pressure results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet obstruction, causing high-pressure detrusor contractions, can result in hydronephrosis from the high detrusor pressure that radiates up the ureters to the renal pelvis. This problem does not normally cause nephritic syndrome or pyelonephritis. Nephrotoxicity results from chemical causes.
The nurse and urologist have both been unsuccessful in catheterizing a client with a prostatic obstruction and a full bladder. What approach does the nurse anticipate the health care provider will use to drain the client's bladder? A. Insertion of a suprapubic catheter B. Scheduling the client immediately for a prostatectomy C. Application of warm compresses to the perineum to assist with relaxation D. Medication administration to relax the bladder muscles and reattempting catheterization in 6 hours
A. Insertion of a suprapubic catheter Rationale: When the client cannot void, catheterization is used to prevent overdistention of the bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may be necessary, but would not be undertaken for the sole purpose of relieving a urethral obstruction. Delaying by applying compresses or administering medications could result in harm.
The nurse on a urology unit is working with a client who has been diagnosed with calcium oxalate renal calculi. When planning this client's health education, what nutritional guidelines should the nurse provide? A. Restrict protein intake as prescribed. B. Increase intake of potassium-rich foods. C. Follow a low-calcium diet. D. Encourage intake of food containing oxalates.
A. Restrict protein intake as prescribed. Rationale: Protein is restricted to 60 g/day, while sodium is restricted to 3 to 4 g/day. Low-calcium diets are generally not recommended except for true absorptive hypercalciuria. The client should avoid intake of oxalate-containing foods and there is no need to increase potassium intake.
The nurse who is leading a wellness workshop has been asked about actions to reduce the risk of bladder cancer. What health promotion action most directly addresses a major risk factor for bladder cancer? A. Smoking cessation B. Reduction of alcohol intake C. Maintenance of a diet high in vitamins and nutrients D. Vitamin D supplementation
A. Smoking cessation. Rationale: People who smoke are significantly more likely to develop bladder cancer than those who do not smoke. High alcohol intake and low vitamin intake are not noted to contribute to bladder cancer.
A client with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the client's post-procedure care? A. Strain the client's urine following the procedure. B. Administer a bolus of 500 mL normal saline following the procedure. C. Monitor the client for fluid overload following the procedure. D. Insert a urinary catheter for 24 to 48 hours after the procedure.
A. Strain the client's urine following the procedure. Rationale: Following ESWL, the nurse should strain the client's urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL.
A 42-year-old woman comes to the clinic reporting occasional urinary incontinence when sneezing. The clinic nurse should recognize what type of incontinence? A. Stress incontinence B. Reflex incontinence C. Overflow incontinence D. Functional incontinence
A. Stress incontinence. Rationale: Stress incontinence is the involuntary loss of urine through an intact urethra as a result of sudden increase in intra-abdominal pressure, such as a result of exertion, sneezing, coughing, or changing positions. Reflex incontinence is loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations usually associated with voiding. Overflow incontinence is an involuntary urine loss associated with overdistension of the bladder. Functional incontinence refers to those instances in which the function of the lower urinary tract is intact, but other factors (outside the urinary system) make it difficult or impossible for the client to reach the toilet in time for voiding.
The nurse is working with a client whose health history includes occasional episodes of urinary retention. What assessment finding would suggest that the client is currently retaining urine? A. The client's suprapubic region is dull on percussion. B. The client is uncharacteristically drowsy. C. The client claims to void large amounts of urine two to three times daily. D. The client takes a beta adrenergic blocker for the treatment of hypertension.
A. The client's suprapubic region is dull on percussion. Rationale: Dullness on percussion of the suprapubic region is suggestive of urinary retention. Clients retaining urine are typically restless, not drowsy. A client experiencing retention usually voids frequent, small amounts of urine and the use of beta-blockers is unrelated to urinary retention.
A female client has been prescribed a course of antibiotics for the treatment of a UTI. When providing health education for the client, the nurse should address what topic? A. The risk of developing a vaginal yeast infection as a consequence of antibiotic therapy B. The need to expect a heavy menstrual period following the course of antibiotics C. The risk of developing antibiotic resistance after the course of antibiotics D. The need to undergo a series of three urine cultures after the antibiotics have been completed
A. The risk of developing a vaginal yeast infection as a consequence of antibiotic therapy. Rationale: Yeast vaginitis occurs in many clients treated with antimicrobial agents that affect vaginal flora. Antibiotics do not affect menstrual periods and serial urine cultures are not normally necessary. Resistance is normally a result of failing to complete a prescribed course of antibiotics.
A client has been successfully treated for kidney stones and is preparing for discharge. The nurse recognizes the risk of recurrence and has planned the client's discharge education accordingly. What preventive measure should the nurse encourage the client to adopt? A. Increasing intake of protein from plant sources B. Increasing fluid intake C. Adopting a high-calcium diet D. Eating several small meals each day
B. Increasing fluid intake. Rationale: Increased fluid intake is encouraged to prevent the recurrence of kidney stones. Protein intake from all sources should be limited. Most clients do not require a low-calcium diet, but increased calcium intake would be contraindicated for all clients. Eating small, frequent meals does not influence the risk for recurrence.
A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population? A. Administer prophylactic antibiotics as prescribed. B. Limit the use of indwelling urinary catheters. C. Encourage frequent mobility and repositioning. D. Toilet residents who are immobile on a scheduled basis.
B. Limit the use of indwelling urinary catheters. Rationale: When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adult's risk of developing a UTI. Regular toileting promotes continence, but has only an indirect effect on the risk of UTIs. Prophylactic antibiotics are not normally given. Mobility does not have a direct effect on UTI risk.
A client with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the client's plan of care? A. Impaired physical mobility related to presence of an indwelling urinary catheter B. Risk for infection related to presence of an indwelling urinary catheter C. Deficient knowledge regarding indwelling urinary catheter care D. Disturbed body image related to urinary catheterization
B. Risk for infection related to presence of an indwelling urinary catheter. Rationale: Fifty percent of all hospital-acquired infections are urinary tract infections (UTI), with a large number being associated with indwelling urinary catheters. This adverse infection is frequently referred to as a CAUTI (catheter associated urinary tract infection) and considered in the United States as a "never event". According to the National Quality Forum (NQF), never events are errors in health care that are identifiable, preventable, and serious for clients. Since the risk of infection is substantial; it is prioritized over functional and psychosocial diagnosis of mobility, knowledge deficits, and disturbed body image for this client.
The clinic nurse is preparing a plan of care for a client with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach? A. Provide medication teaching related to pseudoephedrine sulfate. B. Teach the client to perform pelvic floor muscle exercises. C. Prepare the client for an anterior vaginal repair procedure. D. Provide information on periurethral bulking.
B. Teach the client to perform pelvic floor muscle exercises. Rationale: Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence. None of the other listed interventions have a behavioral approach.
The nurse is teaching a health class of older adults about urinary tract infections (UTI)s. What characteristic of UTIs should the nurse cite? A. Men over age 65 are equally prone to UTIs as women, but are more often asymptomatic. B. The prevalence of UTIs in older men approaches that of women in the same age group. C. Men of all ages are less prone to UTIs, but typically experience more severe symptoms. D. The prevalence of UTIs in men cannot be reliably measured, as men generally do not report UTIs.
B. The prevalence of UTIs in older men approaches that of women in the same age group. Rationale: The antibacterial activity of the prostatic secretions that protect men from bacterial colonization of the urethra and bladder decreases with aging, resulting in increased incidence. Men are not more likely to be asymptomatic and are not known to be reluctant to report UTIs.
A nurse is caring for a female client whose urinary retention has not responded to conservative treatment. When educating this client about self-catheterization, the nurse should encourage what practice? A. Assuming a supine position for self-catheterization B. Using clean technique at home to catheterize C. Inserting the catheter 1 to 2 inches (2.5 to 5 cm) into the urethra D. Self-catheterizing every 2 hours at home
B. Using clean technique at home to catheterize. Rationale: The client may use a "clean" (nonsterile) technique at home, where the risk of cross-contamination is reduced. The average daytime clean intermittent catheterization schedule is every 4 to 6 hours and just before bedtime. The female client assumes a Fowler position and uses a mirror to help locate the urinary meatus. The nurse teaches her to catheterize herself by inserting a catheter 7.5 cm (3 inches) into the urethra, in a downward and backward direction.
A nurse is working with a female client who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment? A. Clearly explain the potential benefits of pelvic floor muscle exercises. B. Ensure the client knows that surgery will be required if the exercises are unsuccessful. C. Arrange for biofeedback when the client is learning to perform the exercises. D. Contact the client weekly to ensure that they are performing the exercises consistently.
C. Arrange for biofeedback when the client is learning to perform the exercises. Rationale: Research shows that written or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted pelvic muscle exercise (PME) uses either electromyography or manometry to help the individual identify the pelvic muscles involved when performing PME. This objective assessment is likely superior to weekly contact with the client. Surgery is not necessarily indicated if behavioral techniques are unsuccessful.
A female client has been experiencing recurrent urinary tract infections. What health education should the nurse provide to this client? A. Bathe daily and keep the perineal region clean. B. Avoid voiding immediately after sexual intercourse. C. Drink liberal amounts of fluids. D. Void at least every 6 to 8 hours.
C. Drink liberal amounts of fluids. Rationale: The client 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 client should be encouraged to shower rather than bathe.
The nurse is caring for a client with an indwelling urinary catheter. The nurse is aware that what nursing action helps prevent infection in a client with an indwelling catheter? A. Vigorously clean the meatus area daily. B. Apply powder to the perineal area twice daily. C. Empty the drainage bag at least every 8 hours. D. Irrigate the catheter every 8 hours with normal saline.
C. Empty the drainage bag at least every 8 hours. Rationale: To reduce the risk of bacterial proliferation, the nurse should empty the collection bag at least every 8 hours through the drainage spout, and more frequently if there is a large volume of urine. Vigorous cleaning of the meatus while the catheter is in place is discouraged, because the cleaning action can move the catheter, increasing the risk of infection. The spout (or drainage port) of any urinary drainage bag can become contaminated when opened to drain the bag. Irrigation of the catheter opens the closed system, increasing the likelihood of infection.
A client has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the client's admission assessment, the nurse should be aware that what signs and symptoms are characteristic of this diagnosis? Select all that apply. A. Diarrhea B. High fever C. Hematuria D. Urinary frequency E. Acute pain
C. Hematuria D. Urinary frequency E. Acute pain Rationale: Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the client has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is not associated with this presentation, and a fever is usually absent due to the noninfectious nature of the health problem.
A client has had a indwelling urinary catheter removed after having it in place for 10 days during recovery from an acute illness. Two hours after removal of the catheter, the client informs the nurse that the client is experiencing urinary urgency resulting in several small-volume voids. What is the nurse's best response? A. Inform the client that urgency and occasional incontinence are expected for the first few weeks post-removal. B. Obtain an order for a loop diuretic in order to enhance urine output and bladder function. C. Inform the client that this is not unexpected in the short term and scan the client's bladder following each void. D. Obtain an order to reinsert the client's urinary catheter and attempt removal in 24 to 48 hours.
C. Inform the client that this is not unexpected in the short term and scan the client's bladder following each void. Rationale: Immediately after the indwelling catheter is removed, the client is placed on a timed voiding schedule, usually every 2 to 3 hours. At the given time interval, the client is instructed to void. The bladder is then scanned using a portable ultrasonic bladder scanner; if the bladder has not emptied completely, straight catheterization may be performed. An indwelling catheter would not be reinserted to resolve the problem, and diuretics would not be beneficial. Ongoing incontinence is not an expected finding after catheter removal.
The nurse is caring for a client who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurse's assessment reveals that the stoma is a dark purplish color. What is the nurse's most appropriate response? A. Document the presence of a healthy stoma. B. Assess the client for further signs and symptoms of infection. C. Inform the primary care provider that the vascular supply may be compromised. D. Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.
C. Inform the primary care provider that the vascular supply may be compromised. Rationale: A healthy stoma is pink or red. A change from this color to a dark purplish color suggests that the vascular supply may be compromised. A loose ostomy appliance and infections do not cause a dark purplish stoma.
The nurse is caring for a client who underwent percutaneous (endourologic) lithotripsy earlier in the day. What instruction should the nurse give the client? A. Limit oral fluid intake for 1 to 2 days. B. Report the presence of fine, sand-like particles through the nephrostomy tube. C. Notify the health care provider about cloudy or foul-smelling urine. D. Report any pink-tin
C. Notify the health care provider about cloudy or foul-smelling urine. Rationale: The client should report the presence of foul-smelling or cloudy urine since this is suggestive of a urinary tract infection (UTI). Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sand-like debris is normal due to residual stone products. Hematuria is common after lithotripsy.
A client with a recent history of nephrolithiasis has presented to the ED. After determining that the client's cardiopulmonary status is stable, what aspect of care should the nurse prioritize? A. IV fluid administration B. Insertion of an indwelling urinary catheter C. Pain management D. Assisting with aspiration of the stone
C. Pain management. Rationale: The client with kidney stones is often in excruciating pain, and this is a high priority for nursing interventions. In the short term, this would supersede the client's need for IV fluids or for catheterization. Kidney stones cannot be aspirated.
A client has been admitted to the postsurgical unit following the creation of an ileal conduit. What should the nurse measure to determine the size of the appliance needed? A. The circumference of the stoma B. The length, then double it C. The widest part of the stoma D. Half the width of the stoma
C. The widest part of the stoma Rationale: The correct appliance size is determined by measuring the widest part of the stoma with a ruler. The permanent appliance should be no more than 1.6 mm (1/8 inch) larger than the diameter of the stoma and the same shape as the stoma to prevent contact of the skin with drainage.
The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a client how to manage a new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices? A. Empty the collection bag when it is between one-half and two-thirds full. B. Limit fluid intake to prevent production of large volumes of dilute urine. C. Reinforce the appliance with tape if small leaks are detected. D. Avoid using moisturizing soaps and body washes when cleaning the peristomal area.
D. Avoid using moisturizing soaps and body washes when cleaning the peristomal area. Rationale: The client is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the collection bag should not be allowed to become more than one-third full.
A client has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this client's high risk for urinary retention and should implement what intervention in the client's plan of care? A. Relaxation techniques B. Sodium restriction C. Lower abdominal massage D. Double voiding
D. Double voiding Rationale: To enhance emptying of a flaccid bladder, the client may be taught to "double void." After each voiding, the client is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction and massage are similarly ineffective.
An adult client has been hospitalized with pyelonephritis. The nurse's review of the client's intake and output records reveals that the client has been consuming between 3 L and 3.5 L of oral fluid each day since admission. How should the nurse best respond to this finding? A. Supplement the client's fluid intake with a high-calorie diet. B. Emphasize the need to limit intake to 2 L of fluid daily. C. Obtain an order for a high-sodium diet to prevent dilutional hyponatremia. D. Encourage the client to continue this pattern of fluid intake.
D. Encourage the client to continue this pattern of fluid intake. Rationale: Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. Consequently, there is no need to supplement this fluid intake with additional calories or sodium.
A gerontologic nurse is assessing a client who has numerous comorbid health problems. What assessment finding(s) should prompt the nurse to suspect a UTI? Select all that apply. A. Food cravings B. Upper abdominal pain C. Insatiable thirst D. Fever E. New onset of confusion
D. Fever E. New onset of confusion Rationale: Early symptoms of UTI in older adults include burning, urgency, and fever. Some clients develop incontinence and delirium with the onset of a UTI. Food cravings, increased thirst, and upper abdominal pain necessitate further assessment and intervention, but none are directly suggestive of a UTI.
A client is postoperative day 3 following the creation of an ileal conduit for the treatment of invasive bladder cancer. The client is quickly learning to self-manage the urinary diversion, but expresses concern about the presence of mucus in the urine. What is the nurse's most appropriate response? A. Report this finding promptly to the primary care provider. B. Obtain a sterile urine sample and send it for culture. C. Obtain a urine sample and check it for pH. D. Reassure the client that this is an expected phenomenon.
D. Reassure the client that this is an expected phenomenon. Rationale: Because mucous membrane is used in forming the conduit, the client may excrete a large amount of mucus mixed with urine. This causes anxiety in many clients. To help relieve this anxiety, the nurse reassures the client that this is a normal occurrence after an ileal conduit procedure. Urine testing for culture or pH is not required.
An older adult has experienced a new onset of urinary incontinence, and family members identify this problem as being unprecedented. When assessing the client for factors that may have contributed to incontinence, the nurse should prioritize what assessment? A. Reviewing the client's 24-hour food recall for changes in diet B. Assessing for recent contact with individuals who have UTIs C. Assessing for changes in the client's level of psychosocial stress D. Reviewing the client's medication administration record for recent changes
D. Reviewing the client's medication administration record for recent changes. Rationale: Many medications affect urinary continence in addition to causing other unwanted or unexpected effects. Stress and dietary changes could potentially affect the client's continence, but medications are more frequently causative of incontinence. UTIs can cause incontinence, but these infections do not result from contact with infected individuals.
A nurse's colleague has applied an incontinence pad to an older adult client who has experienced occasional episodes of functional incontinence. What principle should guide the nurse's management of urinary incontinence in older adults? A. Diuretics should be promptly discontinued when an older adult experiences incontinence. B. Restricting fluid intake is recommended for older adults experiencing incontinence. C. Urinary catheterization is a first-line treatment for incontinence in older adults with incontinence. D. Urinary incontinence is not considered a normal consequence of aging.
D. Urinary incontinence is not considered a normal consequence of aging. Rationale: Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. Diuretics cannot always be safely discontinued. Fluid restriction and catheterization are not considered to be safe, first-line interventions for the treatment of incontinence.
A female client's most recent urinalysis results are suggestive of bacteriuria. When assessing this client, the nurse's data analysis should be informed by what principle? A. Most UTIs in female clients are caused by viruses and do not cause obvious symptoms. B. A diagnosis of bacteriuria requires three consecutive positive results. C. Urine contains varying levels of healthy bacterial flora. D. Urine samples are frequently contaminated by bacteria normally present in the urethral area.
D. Urine samples are frequently contaminated by bacteria normally present in the urethral area. Rationale: Because urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding 105 colonies/mL of clean-catch, midstream urine is the measure that distinguishes true bacteriuria from contamination. A diagnosis does not require three consecutive positive results and urine does not contain a normal flora in the absence of a UTI. Most UTIs have a bacterial etiology.
