Urinary Patterns
The client returns from the Post Anesthesia Care Unit (PACU) after the surgical procedure. The client has an IV of lactated ringers (LR) infusing at 125 mL/hr, O2 at 2 L/min per nasal cannula, and an indwelling catheter attached to a drainage bag. Four hours later, the nurse documents the client's intake/output. The LR solution has been running for 4 hours, and the nurse administers an IV antibiotic that runs in 150 mL of normal saline. The client is still NPO after the procedure. How does the nurse document the client's intake in mL? (Enter numerical value only. If rounding is necessary round to the whole number.)
650 IV: 150 mL x 4 hr = 500 mL of IV solution Total: 500 mL + 150 mL (antibiotic) = 650 mL
The clients incontinence continues. Use of the condom catheter is resumed until the client develops localized dermatitis. The condom catheter is removed temporarily to promote healing. Although the nursing staff takes the client to the bathroom every 2 hours, episodes of incontinence occasionally occurs. The nurse enters the client's room and finds him crying. What is the best initial response by the nurse to this behavior?
Acknowledge the client's distress
The nursing staff continues with bladder-training, but the client's incontinence shows little improvement. Since bladder training has not been successful, the nurse obtains a prescription to apply an external male catheter. Which intervention is most important for the nurse to include in the client's plan of care?
Assess for signs of skin breakdown
The client is responsive but confused and frequently pulls on the urinary catheter. The nurse observes obvious hematuria in the drainage bag and notes the presence of several blood clots in the tubing. How should the nurse document this situation?
Client is confused and pulls on the indwelling catheter. Urine is pinkish-red with blood clots
The student obtains a 16 French indwelling catheter from the supply room. The student nurse explains the procedure to the client, who gives permission to begin. After cleansing the urinary meatus, the student nurse maintains sterile technique while inserting the catheter into the urethra about 4 inches. While inflating the balloon, the client cries out in obvious pain. Which action should the student take?
Deflate the balloon and insert the catheter farther
The client voids after further interventions and is discharged and is discharged from the acute care facility and transferred to the long-term care facility (LTAC). Since the client no longer has an IV, the order for the antibiotic is changed to an oral medication. The client has some difficulty swallowing (dysphagia), and the nurse is considering the best technique to help the client swallow the medication. Before deciding to open the capsule and mix it with food, what will the nurse need to determine?
Determine if the medication is an extended-release form
After reviewing the client's diagnostic test results, the nurse consults with the HCP and receives an order for a new antibiotic. Since the client's creatinine level is elevated, the nurse is concerned about which problem in administering the medication?
Drug toxicity due to reduced drug excretion
The nursing instructor encourages the student nurse to perform the irrigation. The student prepares the solution, applies gloves, clamps the distal tubing, and begins to clean the specimen port on the drainage tubing. What action should the nurse take?
Encourage the student nurse to continue, maintaining aseptic technique
The client's hematuria continues. Two hours later, the client becomes restless and appears to be in pain. The nurse observes that there has been no urinary output during the last 2 hours. Which assessment should the nurse complete first?
Evaluate the urinary drainage tubing
The nurse notes that the mediation dosage is in the safe range for older clients, which is to be administered by IV every 12 hours. The nurse recognizes that the frequency of drug administration is based on which characteristic of the medication?
Half-life
Since the client now voids spontaneously without recognizing the need to void, how should the nurse document the client's current urinary pattern in the medical chart?
Incontinence
The client reports, prior to the stroke, getting up five or six times to urinate nightly but controlled the urge long enough to make it to the bathroom. How should the nurse document the urinary pattern that the client is describing?
Nocturia
The client's confusion decreases, and 12 hours later the nurse is able to remove the wrist restraints. By the third postoperative day, no further hematuria or blood clots are observed in the urine. However, the nurse does observe that the urine has developed a cloudy appearance. Which action should the nurse implement?
Obtain a sterile urine specimen
The nurse consults with the pharmacist, who determines that the capsule can be opened and mixed with a food that the client likes. Which technique should the nurse use?
Open the capsule and mix the medication with pudding
The nurse reviews factors that may impact catheter insertion with the student nurse. Which physiologic change that commonly occurs in adult males may affect insertion of the catheter?
Prostate gland enlargement
Urinalysis results are as follows: pH: 8.5 Specific gravity: 1.015 Protein: 0 g/day Glucose: 0 mmol/L WBC: 8/hpf RBC: 2/hpf Based on the urinalysis results, the HCP orders a broad-spectrum antibiotic. After 24 hours of receiving the antibiotic, the client's condition has not improved. What additional nursing intervention should the nurse implement?
Provide a glass of cranberry juice daily
To help manage the client's incontinence, the nurses initiates a bladder training program. Which instruction should the nurse provide to the unlicensed assistive personnel (UAP) who will be helping care for the client?
Remind the client to void every 2 hours while awake and to call for assistance to the bathroom
After several weeks, the bladder training program in unsuccessful in stopping the client's incontinence. The client appears withdrawn and states that they are frustrated at the number of episodes that continue to occur. Which interventions should the nurse include in the client's plan of care? (Select all that apply. One, some, or all options may be correct.)
Report signs of insomnia due to anxiety Discuss possible coping strategies
Realizing that indwelling urinary catheters increase the risk of developing a urinary tract infection, which intervention should the nurse implement?
Secure the catheter bag to the bed Frame when the client is repositioned on his side
The nurse notifies the HCP of continues confusion and pulling at devices, and obtains an order for wrist restraints. The nurse applies the restraints and plans to monitor the client every 30 minutes. Which assessments are most important for the nurse to perform at each of these times? (Select all that apply. One, some, or all options may be correct.)
Skin integrity of the restrained extremities Pulse rate and volume in the wrists
The nurse is unable to resolve the catheter obstruction using noninvasive measures and notifies the HCP, who orders bladder irrigation to dislodge any blood clots obstructing the urine flow. The nurse anticipates that the order will include the use of which sterile solution to irrigate the catheter?
Sodium chloride (NS)
The client's indwelling catheter is removed by the nurse on the morning of the client's anticipated discharge. Which assessment finding warrants intervention by the nurse?
The client has not voided in 8 hours after catheter removed
During the catheter irrigation, the nurse observes that the client is still confused and attempts to pull at the urinary catheter, IV, and nasal cannula. The nurse considers the use of wrist restraints on the basis of which rationale?
The client is at risk for self-injury
When the client is calm, the nurse assigns the UAP to help the client into dry clothing. Several minutes later, the nurse walks down the hall and sees the UAP in the room changing the client's clothes. The nurse enters the room and assesses the situation. Which aspect of the situation requires the nurse's most immediate intervention?
The client's room door is open to the hallway
To encourage voiding, the nurse instructs the UAP to perform which intervention?
Turn on the tap so water is running when the client attempts to void
Which diagnostic test result would make the nurse concerned that the client is at risk for sepsis?
Urine culture shows resistance to the ordered antibiotic
The client is admitted to the acute care facility for minor surgery. Preoperative orders include the insertion of an indwelling urinary catheter. A student nurse is assigned to care for the client. The nursing instruction asks the student nurse to prepare to insert the indwelling catheter under supervision. What is the first stem in the proper placement of an indwelling urinary catheter for a male client?
Wash perineal area with soap and water
Following an episode of incontinence, the nurse washes the client's perineal area with mild soap and water and applies a water-repellent ointment to the skin. The client's spouse is present and the nurse uses this opportunity to educate them about proper skin care to prevent breakdown. Which statement by the client's spouse indicates that teaching provided was effective?
Wash the area with mild soap and water followed by ointment
The catheter is successfully placed in the bladder with a return of 200 mL of clear, yellow urine. The catheter is secured and the client is resting comfortably. In documenting the catheter insertion procedure, which statement should be included?
16 French indwelling catheter inserted by student nurse, with supervision, with return of 200 mL of clear, yellow urine
The student nurse instills a total of 60 mL of the correct solution and withdraws 40 mL of fluid containing several small blood clots. The student nurse then empties 200 mL from the urinary drainage bag. What urinary output should be recorded? (Enter the numerical value only. If rounding is required, round to the whole number.)
180 200 mL - 20 mL = 180 mL