PrepU ch. 37 Fundamentals

When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?

Check health record for provider's order.

A client could experience increased urination when using which classification of medication?

Cholinergic agents

A client has a cerebrovascular accident and is incontinent of bowel and bladder. Incontinence of urine in this client is related to a:

neurogenic bladder.

A client at a health care facility is being treated for cancer of the bladder. The physician uses a urinary diversion to help the client with urinary elimination. What describes a urinary diversion?

one or both of the ureters are surgically implanted elsewhere

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?

urinary retention

The nurse has an order to obtain a 24-hour urine specimen from a client. Which instruction would be accurate for collection of the specimen?

"Discard your first urine and begin the collection after that."

The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment?

"Do you have the sensation to urinate?"

A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client?

"How frequently do you urinate each day?"

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?

"Let's explore structuring activities and toileting breaks."

A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response?

"Let's review your medication history and whether you consume bladder irritants."

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?

"Void a small amount, stop, and discard it."

The nurse is assessing a female client who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply?

"You are experiencing stress incontinence. Do you know how to do Kegel exercises?"

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

24-hour specimen

The health care provider has prescribed an indwelling catheter for a client. When the nurse explains the procedure, the client refuses to allow placement of the catheter. Which action should the nurse take?

Ask the client why he or she does not want a catheter.

A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?

Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.

The nurse is caring for a client with frequent urinary tract infections (UTIs). What does the nurse include in the client's teaching plan to decrease the incidence of UTIs?

Be sure to urinate after sexual intercourse.

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?

Boys may take longer for daytime continence than girls.

A client admitted to the hospital with chronic renal failure suddenly develops the following signs and symptoms: left arm arteriovenous (AV) fistula has weak thrill and bruit; BP 88/40 mm Hg; stated feels dizzy. Which action would the nurse implement first?

Change to supine position.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

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.

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

A nurse is the guest speaker at a women's club. Most of the women are older than 40 years of age and have asked the nurse to speak about health promotion topics. The nurse states that exercises may help with urinary urgency. Which exercise instruction will the nurse provide to the women?

Contract the pubic muscles for 3 seconds, then relax.

A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?

Contact the health care provider

A nurse assessing an older adult client finds that the client has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause?

Decreased bladder contractility

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?

Fasten the condom securely enough to prevent leakage without constricting blood flow.

The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?

Ensure proper positioning of the scanner head and rescan.

The nurse is preparing a client for an intravenous pyelogram. Which nursing actions are performed correctly? Select all that apply.

Give a laxative the evening before the examination. Withhold food or fluids 12 hours before testing. Give an enema the day of the examination. Obtain client's allergy history.

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

A nurse prepares a client with a recently created ileal conduit to be discharged from the hospital. Which is an expected assessment finding?

Mucus in the urine is a normal finding.

A client is suspected of having a disease process affecting the functional unit of the kidney. Which structure is most likely involved?

Nephron

A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?

Notifying the health care provider of the assessment findings

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.

Perform, or allow client to perform, perineal hygiene at least once daily. Contact the health care provider to ask for an order for catheter discontinuation.

The client is preparing to obtain a clean-catch midstream urine specimen. List in order the steps needed to complete the diagnostic test.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into stool. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.

Which urinary care teaching will the nurse provide to a young adult female client?

Refrain from douching unless ordered by a health care provider.

A nurse is caring for an older adult client who has been prescribed a condom catheter. What potential problems related to the use of a condom catheter should the nurse monitor in the client? Select all that apply.

Restricted blood flow to the glans tissue Excoriation of the skin in the glans area Kinks in tubing that encourage backflow of urine

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence?

Stress

The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?

The birth can cause perineal swelling.

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?

The client has an enlarged prostate.

The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal?

The client is acutely confused and has been diagnosed with delirium.

A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions?

The client should avoid wearing tight clothes or belts near the site.

A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?

The client will have to wear an external appliance to collect urine.

Use of an indwelling urinary catheter leads to the loss of bladder tone.

True

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse's best choice?

Urinal

The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?

Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.

A sterile urine specimen for culture and sensitivity has been prescribed for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?

Withdraw several milliliters of urine from the port on the collection tubing, using aseptic technique.

A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?

a flexible sheath that is rolled around the penis

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?

anuria

The nurse is caring for a client with weakness who is ambulatory but tires easily. Which method for urinary elimination does the nurse recommend?

bedside commode

A woman is reporting bladder urgency. It is most important to assess:

caffeine intake.

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation?

checking that the client has signed a consent form for the procedure

A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?

dark brown, cloudy

The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?

dehydration

A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?

first thing in the morning

A client at a health care facility has been diagnosed with polyuria. How would the nurse describe the client's condition in the medical record?

greater than normal urinary volume

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?

intermittent urethral catheter

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?

straight catheter

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?

stress

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?

stress incontinence

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?

strongly aromatic, dark amber