11 Urinary Elimination
ANSWER: 1 Rationales: 1. A urine output of 100 mL is too little output with an intake of 735 mL over 2 hours and may reflect reduced kidney efficiency in reaction to the contrast dye. This is a serious concern and should be reported to the primary health-care provider. 2. Slight nausea is a mild, not critical, reaction to the contrast dye; however, continued monitoring of this symptom should occur. 3. A headache is a mild, not critical, reaction to the contrast dye; however, ongoing monitoring should occur to ensure that the patient obtains relief. 4. A blood pressure of 150/84 mm Hg is within the expected range of 120 to 160 systolic and 80 to 95 diastolic for a patient who is 70 years of age. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority. All the options reflect information that should be communicated, but one is most essential. but one is most essential.
1. A hospitalized 70-year-old adult has a computed tomography (CT) scan with contrast at 11 a.m. The patient has an IV running at 125 mL per hour and ingested 50 percent of lunch with a cup of coffee and 4 oz of soup at 12 noon. The nurse is going on a break at 1 p.m. and provides the following information to the nurse accepting responsibility for the patient. Which information about the patient is of most concern to the nurse accepting responsibility for the patient? 1. Urine output - 100 mL 2. Presence of slight nausea 3. Medicated for a mild headache 4. Blood pressure - 150/84 mm Hg
1. Answer: 4. Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (option 4). Older adults do not ignore the urge to void and may have difficulty in getting to the toilet in time (option 2). The kidney becomes less able to concentrate urine with age (option 3).
1. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following? 1. The bladder distends and its capacity increases. 2. Older adults ignore the need to void. 3. Urine becomes more concentrated. 4. The amount of urine retained after voiding increases.
1. The urine output of a patient in cardiogenic shock has been 200 mL for the last 24 hours and serum creatinine level is 1.5 mg/dL. Which lab value indicates to the nurse that the patient might be in acute kidney failure? Answer: Sodium level is 125 mg/dL.
1. The urine output of a patient in cardiogenic shock has been 200 mL for the last 24 hours and serum creatinine level is 1.5 mg/dL. Which lab value indicates to the nurse that the patient might be in acute kidney failure? • BUN is 16 mg/dL. • Calcium is 8.7 mg/dL. • Sodium level is 125 mg/dL. • Potassium is 4.8 mEq/L.
10. The nurse is counseling a patient with end-stage renal disease who is trying to decide between hemodialysis and peritoneal dialysis as the method of treatment. What information should the nurse keep in mind when meeting with this patient to assess for the appropriate treatment? (Select all that apply.) Answers: Hemodialysis requires that the patient adhere to a strict diet. Only about a third of hemodialysis patients survive 5 years of treatment. Hemodialysis requires 2-3-hour treatments about three times per week.
10. The nurse is counseling a patient with end-stage renal disease who is trying to decide between hemodialysis and peritoneal dialysis as the method of treatment. What information should the nurse keep in mind when meeting with this patient to assess for the appropriate treatment? (Select all that apply.) • Hemodialysis requires that the patient adhere to a strict diet. • Only about a third of hemodialysis patients survive 5 years of treatment. • Peritoneal dialysis requires a surgical shunt formation. • Hemodialysis requires 2-3-hour treatments about three times per week. • Infection is not a concern with peritoneal dialysis.
10. The nurse recognizes when assessing a patient that there is an increased risk of developing kidney disease if the patient: (Select all that apply.) Answers: Is treated for hypertension. Has benign prostatic hypertrophy.
10. The nurse recognizes when assessing a patient that there is an increased risk of developing kidney disease if the patient: (Select all that apply.) • Is of Asian descent. • Is treated for hypertension. • Has a grandmother with type II diabetes. • Is being treated for an upper respiratory tract infection. • Has benign prostatic hypertrophy.
10. ANSWER: 3. Rationales: 1. Although placing a patient's hands in warm water may initiate micturition, it is not the most effective intervention to facilitate complete bladder emptying. 2. Although stroking the inner aspect of a patient's thigh may initiate micturition, it is not the most effective intervention to facilitate complete bladder emptying. 3. Encouraging a patient to wait until urine stops flowing and then attempting to void again (double void) may facilitate complete bladder emptying. A small amount of urine remains in the bladder after voiding (residual urine), which can support bacterial growth; therefore, complete bladder emptying contributes to a decreased risk of bladder infection. 4. Although sounds of flowing water may initiate micturition, it is not the most effective intervention to facilitate complete bladder emptying. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority. Identify the unique option. Option 3 is unique because the actual action used to completely empty the bladder is performed by the patient, not the nurse.
10. Which nursing intervention is most effective when assisting a patient to completely empty the bladder? 1. Place the patient's hands in warm water. 2. Stroke an inner aspect of the patient's thigh. 3. Encourage the patient to attempt to double void. 4. Turn a faucet on in the patient's room to produce sounds of flowing water.
Answer: 2 and 5. Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced. Some clients may need diapers; this is not the BEST indicator of a successful program (option 3). Citrus juices may irritate the bladder (option 4). Carbonated beverages increase diuresis and the risk of incontinence (option 4).
10. Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply. 1. Voids each time there is an urge. 2. Practices slow, deep breathing until the urge decreases. 3. Uses adult diapers, for "just in case." 4. Drinks citrus juices and carbonated beverages. 5. Performs pelvic muscle exercises.
11. ANSWER: 2. Rationales: 1. Avoiding lifting heavy objects is an intervention to reduce incontinence associated with stress, not urge, incontinence. 2. Caffeine irritates the mucosa of the bladder and should be avoided to reduce bladder irritability and urge incontinence. 3. The Credé maneuver, application of pressure over the bladder, is used to promote emptying of the bladder. It is not used to gain better bladder control as a result of urge incontinence. 4. With urge incontinence, the person should be taught to slowly deep breathe to reduce the sense of urgency so that more time elapses between voidings.
11. A patient reports signs and symptoms associated with urge incontinence. Which action should the nurse teach the patient to employ to gain better bladder control? 1. Avoid lifting heavy objects. 2. Avoid products with caffeine. 3. Use the Credé maneuver when voiding. 4. Respond immediately to the sensation to void.
12. ANSWER: 1, 2, 4, 6. Rationales: 1. This patient is experiencing functional incontinence. Functional incontinence involves the inability to get to the bathroom in time because of environmental factors or sensory, cognitive, or mobility issues. This patient has impaired mobility and dexterity of the hands. Velcro closures, instead of buttons and zippers, may facilitate quicker disrobing to urinate. 2. A lift chair will facilitate moving from a sitting to standing position shortening the time it takes to move to a bathroom to void. 3. Avoiding products with caffeine is encouraged to reduce bladder irritability associated with urge, not functional, incontinence. 4. A commode positioned nearby will reduce the distance a person with a mobility problem has to move to get to a toilet. 5. Kegel exercises are recommended to strengthen weak pelvis muscles associated with stress and urge, not functional, incontinence. 6. Voiding at timed intervals avoids waiting until a bladder is full and, as a result, enables more time to move to the bathroom or commode.
12. A home-care nurse is caring for a cognitively intact woman who has arthritis that affects her hands and slows her mobility. The patient tells the nurse about having a few episodes of urinary incontinence that were upsetting. The nurse identifies that the patient is experiencing functional incontinence. Which nursing interventions in the plan of care are specific to limiting episodes of incontinence in this patient? Select all that apply. 1. Encourage wearing clothing with Velcro closures instead of buttons and zippers. 2. Suggest purchasing a lift chair if economics permit. 3. Encourage avoiding products with caffeine. 4. Teach to position a commode nearby. 5. Teach the patient Kegel exercises. 6. Suggest voiding every 2 hours.
13. ANSWER: 4. Rationales: 1. Cotton underwear should be worn because nylon prevents evaporation of moisture. Bacteria multiply in a warm, moist, dark environment. 2. The patient should urinate after, not before, intercourse to flush away bacteria that may have entered the urethra during sexual activity. 3. Bubble baths and baking-soda baths should be avoided because they increase the risk of a urinary tract infection. 4. Voiding immediately when the urge is perceived helps to avoid stagnant urine in the bladder. Bacteria multiply in stagnant urine. TEST-TAKING TIP: Identify the clang association. The word urinary in the stem and the word urinate in option 4 is a clang association. Examine this option carefully when considering which option is the correct answer.
13. A nurse is caring for a female patient who has a history of frequent urinary tract infections. What should the nurse teach the patient to do? 1. Wear nylon underwear. 2. Void before having intercourse. 3. Take a bubble bath rather than showering. 4. Urinate when the urge to urinate is perceived.
14. ANSWER: 4. Rationales: 1. Compression here may permanently compromise the patency of the lumen than drains urine from the bladder and the lumen that permits inflation and deflation of the balloon. 2. Compression here may permanently compromise the patency of the lumen that drains urine from the bladder. 3. Compression here may permanently compromise the patency of the lumen that permits inflation and deflation of the balloon. 4. Compression at this site will interrupt the flow of urine from the urinary bladder to the urine collection bag. Urine will collect above the specimen port in the drainage tubing without compromising the integrity of the urinary catheter. TEST-TAKING TIP: Identify the unique option. Option 4 is unique. Options 1, 2, and 3 are related to the catheter. Option 4 is related to the collection bag tubing. Examine option 4 carefully.
14. A patient has a urinary retention catheter in place. The nurse must obtain a sterile urine specimen for culture and sensitivity. Where should the nurse place the clamp to allow urine to collect in the tubing so that the nurse can collect a specimen? 1. A 2. B 3. C 4. D
15. ANSWER: 2. Rationales: 1. Immobility is more likely to contribute to urinary incontinence than urinary retention because of a decrease in bladder tone. 2. The bladder loses tone while a urinary retention catheter is in place. Intake and output should be monitored after its removal because urinary retention is a potential problem. If urinary retention occurs, the primary health-care provider will either order the patient to be straight catheterized and output monitored for another 8 hours or the urinary retention catheter will be reordered. 3. Disorientation to time, place, and person is more likely to contribute to urinary incontinence than urinary retention because of a decreased ability to comprehend and react to the sensation of a full bladder. 4. Urinary retention is not a complication associated with a fluid restricted diet. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority. Identify the option with the clang association. The word retention in the stem and in option 2 is a clang association. More often than not, an option with a clang association is the correct answer. Examine option 2 carefully.
15. A nurse is caring for a group of patients. Which patient should cause the most concern about potential urinary retention? 1. The patient who is immobile in bed 2. The patient who just had a retention catheter removed 3. The patient who is disoriented to time, place, and person 4. The patient who just was placed on a fluid restricted diet
16. ANSWER: 3. Rationales: 1. Ten in the morning is too early to ambulate the patient. The surgeon's orders indicate that the patient should be ambulated around the room during the p.m. hours. 2. Although this is an independent function of the nurse and should be encouraged when caring for postoperative patients, it is not the first thing the nurse should do from among the options presented. 3. It is 1 hour since the last assessment and the hourly urine collection container should be emptied into the large chamber of the collection device. Monitoring hourly urine output helps to assess cardiac and renal status and accuracy is essential. 4. The sequential compression devices should only be turned off and removed when the patient is out of bed. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word first in the stem sets a priority.
16. A nurse is caring for a postoperative patient with a urinary retention catheter. The nurse reviews the surgeon's orders, reviews the last nursing progress note, and performs a physical assessment of the patient. Surgeon's Postoperative Orders 0900 IVF 0.9% Sodium Chloride at 50 mL/hour. Full liquid diet progress to 2-g Na diet as tolerated. I&O. Ambulate in room this p.m. and progress to 50 feet bid in a.m. Apply sequential compression devices when in bed. OOB in chair for meals starting noon tomorrow. Maintain Foley to bedside collection bag. Heparin 5,000 units Sub-Q bid. PCA: Dilaudid 1 mg/hour with 0.2 mg/15-minute lockout, not to exceed 7.2 mg in 4 hours. Colace 100 mg PO daily. Progress Notes 0900 Patient received from the PACU at 0900; vital signs stable. Alert to time, place, and person. States that pain is a level 2 and tolerable. Abdominal dressing dry and intact. IVF 0.9% NS in right antecubital space; site dry, and intact; running at 50 mL/hour. PCA infusion site is dry and intact and infusion pump is set at ordered rate. 60 mL noted in hourly urine collection chamber and emptied into the main collection chamber. Urine is straw colored, no sediment noted. Nurse's Physical Assessment 1000 Patient resting in bed; vital signs stable; patient states pain is tolerable on a level 3 and it was unnecessary to push the PCA pump during the last hour. Dressing dry and intact; 70 mL urine noted in hourly urine chamber. 100 mL oral fluids tolerated. IVF 0.9% NS running at 50 mL/hour. States a desire to engage in ankle pumping exercises. Which action should the nurse perform first? 1. Ambulate the patient in the room. 2. Encourage coughing and deep breathing. 3. Empty the patient's urine collection chamber hourly. 4. Turn off the compression device during ankle pumping exercises.
17. ANSWER: 4. Rationales: 1. Urinary retention catheters are not used to make it more convenient for the nursing staff to care for a patient. A urinary retention catheter increases the risk for a bladder infection; therefore, it is used only when absolutely necessary. 2. Urinary retention catheters generally are not used to make it more convenient for the patient. The risk of infection outweighs the benefit to the patient. Exceptions include when a urinary retention catheter is used to protect a patient from urinary incontinence when a person is actively dying or when a patient has a large sacral pressure ulcer. 3. Urinary retention catheters are never used to make it more convenient for the nursing staff to contain or collect urine. 4. After abdominal or thoracic surgery, assessing hourly urine production is an effective way to assess kidney and circulatory function. Also, hourly urine production may be monitored to assess a nonsurgical patient who is in critical condition. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority. Identify the options that are equally plausible. Options 1 and 2 are both concerned with care being more convenient. Option 1 is no better than option 2. Eliminate options 1 and 2 from further consideration. Identify the options with a clang association. The words urinary and catheter in the stem and in options 3 and 4 are clang associations. Examine options 3 and 4 carefully.
17. A patient is scheduled for thoracic surgery and is told by the surgeon that after surgery a catheter will be placed in the bladder. After the surgeon leaves, the patient asks the nurse, "Why am I going to have a tube in my bladder when I am having surgery in my chest?" Which response by the nurse is most appropriate? 1. "It is more convenient to control urine flow rather than having to clean a patient after being incontinent." 2. "We want patients to rest after your type of surgery. You will not be burdened with having to use a bedpan or urinal." 3. "A urinary catheter enables us to easily secure a urine specimen for laboratory tests that generally are ordered after surgery." 4. "Hourly urine production is monitored with a urinary catheter. It is an effective way to assess kidney and circulatory function."
18. ANSWER: 1. Rationales: 1. Seven diapers is too small a number of soiled diapers daily for an infant who is several weeks old. 2. Eight soiled diapers daily is expected for a 3-week-old infant. A well-hydrated infant who is several weeks old produces enough urine to soil 8 to 10 diapers daily. 3. Nine soiled diapers daily is expected for a 3-week-old infant. A well-hydrated infant who is several weeks old produces enough urine to soil 8 to 10 diapers daily. 4. Ten soiled diapers daily is expected for a 3-week-old infant. A well-hydrated infant who is several weeks old produces enough urine to soil 8 to 10 diapers daily. TEST-TAKING TIP: Identify the words in the stem that establish negative polarity. The words cause the most concern asks the test-taker to identify an assessment that is unexpected.
18. A nurse is caring for a 3-week-old infant. Which assessment regarding the number of diapers the infant soils daily should cause concern? 1. 7 2. 8 3. 9 4. 10
19. ANSWER: 1, 2, 4. Rationales: 1. Perineal care should be provided three times a day and whenever necessary, such as after passing of stool, for all patients with urinary retention catheters. 2. Positioning the collection container below the level of the pelvis is common for all types of urinary retention catheters. This prevents the flow of urine back into the bladder, which can cause an infection. 3. All urinary retention catheter balloons should be filled with sterile water because saline will crystallize, resulting in partial deflation of the balloon when it is removed. A partially deflated balloon will cause trauma to the urethral mucosa during removal. 4. The collection bag should be hung on the bed frame, not the side rail, for all types of urinary retention catheters. A bed rail should not be used because when the rail is raised it could raise the collection bag higher than the pelvis. When the rail is lowered it could cause strain on the catheter or pull the catheter out, causing trauma to the urethra. 5. A catheter should be taped to the abdomen, not the thigh, of a male patient. A catheter can be taped to the inner thigh of a female patient.
19. A nurse is caring for a group of patients with a variety of urinary retention catheters. Which of the following nursing interventions are common to all types of urinary catheters? Select all that apply. 1. Provide perineal care three times a day and whenever necessary. 2. Position the collection container below the level of the pelvis. 3. Ensure that the balloon is filled with sterile saline. 4. Hang the collection bag on the bed frame. 5. Tape the catheter to the inner thigh.
ANSWER: 4. Rationales: 1. Although scheduled voiding may be done initially, it does not specifically address overcoming the urge to void. 2. Although wearing an incontinence brief may provide a patient with a sense of security, it will not help reduce the urge to void. 3. People with urge incontinence often void every time they leave the house and stay close to a bathroom to minimize the risk of incontinence. While this action may prevent incontinence, it does not help to reduce the urge to void. 4. Deep, slow breathing helps to progressively relax a person and has proven successful in reducing the urge sensation. Additional interventions include strengthening perineal muscles (Kegel exercises), biofeedback, lifestyle modifications (e.g., avoidance of caffeine, weight reduction, and fluid modifications), and intake of antimuscarinic agents. TEST-TAKING TIP: Identify the options with specific determiners. The words every in options 1 and 3 and only in option 2 are specific determiners. Rarely are options with specific determiners the correct answer. Examine option 4 carefully.
2. A nurse is assisting a female patient who is experiencing numerous daily episodes of urge incontinence to gain better bladder control. Which outcome reflects achievement of a goal associated with this patient's urge incontinence? 1. Urinates every two hours while remaining dry between voiding 2. Wears an adult incontinence brief only when venturing outside the home 3. Empties the bladder every time before leaving the house, limiting incontinence 4. Uses deep, slow breathing until the sensation to void subsides, increasing intervals between voiding
2. A patient with suspected pyelonephritis has urine sent for analysis and culture. The nurse checks for which result to substantiate the diagnosis? Answer: Casts in the urine
2. A patient with suspected pyelonephritis has urine sent for analysis and culture. The nurse checks for which result to substantiate the diagnosis? • High specific gravity • Low leukocyte count • Casts in the urine • Negative for protein
2. Answer: 1, 2, 4, and 5. Rationale: The perineum may become irritated by the frequent contact with urine (option 1). Normal fluid intake is at least 1,500 mL/day and clients often decrease their intake to try to minimize urine leakage (option 2). UTIs can contribute to incontinence (option 4). A fecal impaction can compress the urethra, which can result in small amounts of urine leakage (option 5). Antihistamines can cause urinary retention rather than incontinence (option 3).
2. During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply. 1. Perineal skin irritation 2. Fluid intake of less than 1,500 mL/day 3. History of antihistamine intake 4. History of frequent urinary tract infections 5. A fecal impaction
20. ANSWER: 1, 3, 2, 4, 5. Rationales: 1. First: Washing the hands limits the presence of microorganisms. The nurse should don clean gloves because they protect the nurse from blood and body fluids. 3. Second: Wash the genital area and allow it to dry to remove soiled matter, prevent specimen contamination, and prepare the skin for adhesion of the collection bag. 2. Third: Apply the collection device to enable the collection of a urine specimen. 4. Fourth: Remove the bag immediately after the infant voids to ensure that a fresh sample of urine is tested. 5. Fifth: The entire bag should be sent to the laboratory because it is difficult to remove urine from an infant collection bag. In addition, it protects the specimen from contamination by environmental elements.
20. Place these interventions in the order that they should be performed when collecting a urine specimen from an infant. 1. Wash the hands and don clean gloves. 2. Apply a collection device over the genitals. 3. Wash the genital area and allow the area to dry. 4. Remove the collection bag once the infant urinates. 5. Send the entire bag in a specimen container to the laboratory.
21. ANSWER: 1, 2, 3. Rationales: 1. The correct reagent must be used to ensure reliable results. 2. Adequate lighting facilitates accurate interpretation of the color chart with the dipstick. 3. The kit must not be past the expiration date to ensure reliable results. 4. The procedure may be delegated to unlicensed assistive personnel as long as the individual knows how to perform the skill. Have the person report the results, but have the specimen saved in case the urine has to be retested. 5. The strip should be read at the exact time indicated on the bottle label; waiting times may vary depending on the manufacturer's instructions.
21. Which of the following is essential to ensure reliable bedside dipstick testing of urine? Select all that apply. 1. Use the correct reagent. 2. Ensure adequate lighting. 3. Ensure that the kit is not past the expiration date. 4. Avoid delegating the procedure to another nursing team member. 5. Read the test results one minute after dipping the test strip in urine.
22. ANSWER: 1, 3, 4. Rationales: 1. Presence of thirst is the first symptom of fluid volume loss. An elevated specific gravity of 1.032 most commonly indicates a state of fluid volume deficit or dehydration; as the kidneys attempt to conserve water, the urine becomes more concentrated. The expected range of specific gravity is 1.001 to 1.029. 2. Peripheral edema is a sign of fluid volume excess, not a sign of fluid volume deficit. 3. Decreased skin turgor is a sign of fluid volume deficit, as is a specific gravity of 1.032. Fluid is pulled from the intracellular and interstitial spaces into the vascular compartment, causing decreased skin turgor and dry skin and mucous membranes. 4. A rapid, weak pulse is a sign of fluid volume deficit, as is a specific gravity of 1.032. The heart rate increases as blood vessels constrict in response to less fluid in the circulation and in an attempt to meet the body's peripheral cellular needs. The volume of the pulse is weak (thready) because of hypovolemia. 5. A decrease in blood urea nitrogen occurs with fluid volume excess, not deficit. In fluid volume deficit, the blood urea nitrogen level increases because there is less fluid in proportion to the solid substances in the blood.
22. A patient's specific gravity is 1.032. For what additional clinical indicators should the nurse assess the patient? Select all that apply. 1. Presence of thirst 2. Peripheral edema 3. Decreased skin turgor 4. Rapid, weak pulse rate 5. Decreased blood urea nitrogen
23. ANSWER: 2. Rationales: 1. It is not necessary to wait until the morning to begin the test again. 2. This is the most appropriate action by the nurse. The test is based on urine collected during any 24-hour time period. 3. This action is inappropriate and will cause inaccurate test results. 4. Although the primary health-care provider should be notified of the delay in the test, it is not the priority at this time.
23. A nurse is caring for a patient who is having urine collected for a 24-hour urine test. During the afternoon of the testing period, the patient forgets and accidentally voids into the toilet but tells the nurse right away. What should the nurse do? 1. Start the test again in the morning. 2. Identify the time and begin a new test. 3. Add the time since the previous voiding to the end of the test. 4. Notify the primary health-care provider about the delay of the test.
24. ANSWER: 3. Rationales: 1. A sweet, fruity odor to urine is associated with incomplete fat metabolism related to diabetes mellitus or starvation, not a UTI. The sweet, fruity odor is caused by excess glucose in the urine. 2. Dark, amber urine is caused by high levels of bilirubin in the urine associated with liver dysfunction, not a UTI. Urine may also be dark amber if the urine is very concentrated. 3. Cloudy urine is caused by the presence of bacteria, white blood cells, and/or red blood cells associated with a UTI. 4. Foamy urine is caused by protein in the urine and is associated with renal disease, not a UTI.
24. A nurse is assessing a patient with the diagnosis of urinary tract infection (UTI). Which clinical indicator identified by the nurse supports this medical diagnosis? 1. Sweet, fruity odor to the urine 2. Dark amber color of urine 3. Cloudy urine 4. Foamy urine
25. ANSWER: 1, 2, 4. Rationales: 1. Dysuria (pain or burning on urination) is caused by urine flowing over inflamed mucosal tissue and is associated with a UTI. 2. Hematuria (blood-tinged urine) is caused by irritation of the bladder and urethral mucosa and is associated with a UTI. 3. Urinary frequency, not retention, is associated with a UTI. Urinary retention is associated with the inability of the bladder to empty because of obstruction, inflammation and swelling, neurological problems, anxiety, or an adverse effect of a medication. 4. Urgency (an overwhelming sensation of the need to void) is caused by bladder irritability secondary to a UTI. 5. A distended suprapubic area is associated with urinary retention, not a UTI. TEST-TAKING TIP: Identify equally plausible options. Options 3 and 5 are equally plausible. The suprapubic area will be distended with urinary retention. These options can be eliminated from consideration.
25. A nurse is caring for a patient with a diagnosis of UTI. Which clinical indicators identified during a nursing assessment support the medical diagnosis? Select all that apply. 1. Dysuria 2. Hematuria 3. Urinary retention 4. Urgent sensation to void 5. Distended suprapubic area
26. ANSWER: 3, 4, 5. Rationales: 1. Blood-tinged urine is caused by irritation of the bladder and urethral mucosa associated with a urinary tract infection, not retention. 2. Amber colored urine is associated with concentrated urine related to dehydration or high levels of bilirubin related to liver dysfunction. 3. Abdominal pressure occurs as the bladder fills beyond a comfortable level of stretch, which is associated with urinary retention. 4. When the bladder is distended, it rises up out of the pelvis and is identified when the lower abdomen is palpated. 5. With urinary retention, pressure builds in the bladder to where the external urethral sphincter is unable to maintain closure. It opens temporarily and a small amount of urine escapes until pressure subsides and the sphincter closes. This can happen several times every hour and is a classic sign of urinary retention. It is called urinary retention with overflow.
26. A nurse is assessing a patient and is concerned that the patient may be experiencing urinary retention. Which clinical indicators support this conclusion? Select all that apply. 1. Blood-tinged urine 2. Amber colored urine 3. Reports of abdominal pressure 4. Lower abdominal distention on palpation 5. Voiding small amounts of urine at a time
27. ANSWER: 3. Rationales: 1. Removing the catheter and inserting a retention catheter is contraindicated because it increases the risk of a bladder infection. In addition, the retention catheter will continue to empty the bladder which may precipitate bladder spasms. 2. Continuing to empty the patient's bladder after 750 mL has been removed may precipitate bladder spasms. 3. Releasing the urine over 20 minutes decreases irritability as the bladder distention is relieved; this will help reduce bladder spasms. 4. Removing the catheter and recatheterizing the patient is contraindicated because doing so increases the risk of a bladder infection. TEST-TAKING TIP: Identify equally plausible options. Options 1 and 4 are equally plausible. They both involve inserting a urinary catheter. Identify the options that are opposites. Options 2 and 3 are opposites. Examine options 2 and 3 carefully.
27. A patient has urinary retention and the primary health-care provider orders a straight catheterization. The draining volume reaches 750 mL without completely emptying the bladder. What alternative does the nurse have to help prevent bladder spasms? 1. Remove the catheter and reinsert a retention catheter. 2. Continue the complete emptying of the patient's bladder. 3. Release the remaining urine in the bladder slowly over 20 minutes. 4. Take the catheter out and then recatheterize the patient in 20 minutes.
28. ANSWER: 1, 2, 3, 4. Rationales: 1. A foreign body in a body cavity increases the risk for an infection. Vital signs will increase when the patient has an infection. 2. Cleansing the perineal area reduces the risk of a urinary tract infection. It removes debris and microorganisms away from the urinary meatus. 3. When a urinary drainage tube is kinked or compressed, it interferes with drainage of urine and urine will back up into the bladder. Stasis of urine increases the risk of a bladder infection. 4. These assessments are necessary for identifying the presence of a urinary tract infection. Urine that is cloudy or pink may indicate the presence of an infection. 5. Attaching the drainage bag to the bed railing is contraindicated because, if the railing is raised, urine may flow back into the bladder. Also, if the rail is raised or lowered with the bag attached, it may cause trauma to the urinary meatus. 6. Positioning the urinary drainage bag above the bladder is contraindicated; this will cause urine to flow back into the bladder.
28. A nurse is caring for a patient who has an indwelling urinary catheter. Which nursing actions are important to include in this patient's plan of care? Select all that apply. 1. Obtain the vital signs routinely. 2. Cleanse the perineal area several times a day. 3. Monitor the tubing for kinks and obstructions. 4. Assess the urine for color, cloudiness, and volume. 5. Attach the drainage collection bag to the bed railing. 6. Position the drainage bag above the level of the bladder.
29. ANSWER: 3. Rationales: 1. A straight catheter has one lumen and is used for onetime bladder drainage. 2. An indwelling catheter is a double-lumen catheter used for ongoing bladder drainage. One lumen permits passage 644 Unit IV Basic Human Needs and Related Nursing Care of sterile water for balloon inflation and the other for urinary drainage. 3. A triple-lumen catheter is used for continuous bladder irrigation. One lumen permits passage of sterile water for balloon inflation, another for instilling a GU irrigant into the bladder, and the third for bladder drainage (combination of urine and GU irrigant). 4. A double-lumen catheter is used as an indwelling catheter. TEST-TAKING TIP: Identify the options that are equally plausible. Options 2 and 4 are equally plausible because they both have two lumens. These options can be deleted from further consideration.
29. A nurse receives an order to initiate continuous bladder irrigation. Which catheter should the nurse choose to perform the procedure correctly? 1. Straight catheter 2. Indwelling catheter 3. Triple-lumen catheter 4. Double-lumen catheter
ANSWER: 1, 2, 3. Rationales: 1. Voiding small amounts of urine several times hourly is characteristic of urinary retention. Pressure within the bladder increases as urine collects until the external urethral sphincter is unable to hold back the urine and voiding of small amounts of urine occurs (retention with urinary overflow). 2. When the bladder fills to capacity, it rises up out of the pelvis and can be palpated over the symphysis pubis; this is characterized as bladder distention. 3. Retained urine causes stretching of the bladder wall which precipitates a feeling of pressure, discomfort, and tenderness over the symphysis pubis. 4. Dysuria or pain on urination most often is associated with bladder infection, not urinary retention. 5. Blood-tinged urine most often is associated with irritation of or trauma to the bladder and urethral mucosa (e.g., bladder infection, bladder cancer, physical trauma).
3. A nurse identifies that a patient may be experiencing urinary retention. Which clinical indicators support this inference? Select all that apply. 1. Voiding small amounts of urine several times hourly 2. Abdominal palpation indicating bladder distention 3. Tenderness over the symphysis pubis on palpation 4. Dysuria on urination 5. Blood-tinged urine
3. A patient has been diagnosed with the onset of acute kidney injury. What does the nurse recognize as a prerenal precipitating cause in the patient? Answer: Congestive heart failure
3. A patient has been diagnosed with the onset of acute kidney injury. What does the nurse recognize as a prerenal precipitating cause in the patient? • Urinary calculi • Recent intravenous pyelogram with contrast dye • Congestive heart failure • Crushing injury
3. When percussing a patient's bladder, the nurse hears a dull sound. Which of the following would this sound indicate? Answer: A full bladder
3. When percussing a patient's bladder, the nurse hears a dull sound. Which of the following would this sound indicate? • An empty bladder • A bladder obstruction • Kidney stones • A full bladder
Answer: 2. Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight. A 1-in. space should be left between the penis and the end of the condom (option 1). The condom is changed every 24 hours (option 3), and the tubing is taped to the leg or attached to a leg bag (option 4). An indwelling catheter is secured to the lower abdomen or upper thigh.
3. Which action represents the appropriate nursing management of a client wearing a condom catheter? 1. Ensure that the tip of the penis fits snugly against the end of the condom. 2. Check the penis for adequate circulation 30 minutes after applying. 3. Change the condom every 8 hours. 4. Tape the collecting tubing to the lower abdomen.
30. ANSWER: 3, 4, 1, 6, 2, 5. Rationales: 3. Equipment used for a bladder catheterization often contains sterile gloves and catheters that are composed of latex. Latex-free supplies can be obtained if the patient is allergic to latex. 4. The outside of a sterile package is not sterile and can be touched with the hands. 1. After a sterile field is established, sterile gloves must be worn to maintain sterility of the field and the equipment touched during the procedure. 6. Cleaning the urethral meatus with the provided antiseptic removes debris and microorganisms; this limits the risk of a bladder infection. 2. A lubricated catheter tip limits trauma to the urinary meatus and mucous membranes of the urinary tract. 5. Advancing the catheter 1 inch after urine flows ensures that the catheter is past the internal and external urinary sphincters.
30. A nurse is to perform a onetime bladder catheterization. The nurse verifies the primary health-care provider's order, washes the hands, and identifies the patient. Place the following steps of the procedure in the order in which they should be performed. 1. Don sterile gloves. 2. Lubricate the catheter tip. 3. Assess the patient for a latex allergy. 4. Unwrap the catheter kit creating a sterile field. 5. Advance the catheter 1 inch after urine begins to flow. 6. Clean the urethral meatus with the solution provided in the kit.
31. ANSWER: 2. Rationales: 1. An attempt should be made to reestablish patency of the catheter lumen before obtaining an order for irrigation. 2. Three hours should produce a minimum of 90 mL of urine, even if the patient had no fluid intake. Milking the tubing should be performed first to dislodge sediment or mucus plugs that may be interfering with the flow of urine. 3. Palpating the patient's suprapubic area may not reveal distention because 90 mL is a small fraction of bladder capacity. 4. Some action is required because urine output over three hours should be at least 90 mL (i.e., 30 mL/hour). TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word first in the stem sets a priority. Identify the clang association. The word catheter in the stem and in options 1 and 2 are clang associations. Examine options 1 and 2 carefully. More often than not, an option with a clang association is the correct answer.
31. A postoperative patient has an indwelling catheter that has not drained urine in 3 hours. What should the nurse do first? 1. Ask the primary health-care provider for an order to irrigate the catheter. 2. Milk the tubing to dislodge any mucus or sediment in the catheter. 3. Palpate the patient's suprapubic area to assess for distention. 4. Recognize the patient's status is within expected limits.
32. ANSWER: 2. Rationales: 1. One hour is too long a period of time to wait between assessments of tube patency with a CBI. The volume of output should be checked every 15 minutes. The faster the flow rate, the more frequently the nurse should assess the output. If the tube becomes obstructed soon after being checked and it is not reassessed for a long period of time, then a large volume of urine and solution can collect in and distend the bladder; this increases the potential of injury to the operative site as well as result in reflux to the kidneys. 2. Increasing the flow rate of the irrigating solution helps to dilute the effluent from the bladder, thereby minimizing the formation of clots in the urine. A pink effluent, without the presence of clots, is the clinical indicator that indicates that the irrigating solution flow rate is sufficient to maintain patency. 3. A CBI requires a triple-lumen, not double-lumen, urinary retention catheter. One lumen is attached to the urine collection bag, a second lumen is used to inflate the balloon that holds the catheter in the bladder, and a third lumen is attached to the tubing from the irrigation solution bag. 4. A patient may be encouraged to turn from side to side to facilitate respirations, relieve pressure on bony prominences, and promote venous return from the lower extremities, not to promote urinary elimination. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word essential in the stem sets a priority. Identify the clang association. The word irrigation in the stem and in option 2 is a clang association. More often than not, an option with a clang association is the correct answer. Examine option 2 carefully.
32. A nurse is caring for a patient receiving continuous bladder irrigation (CBI). Which nursing action is essential when caring for this patient? 1. Check the volume of the patient's output every hour to ensure tube patency. 2. Increase the irrigation solution flow rate until the return flow is pink and free from clots. 3. Irrigate the double-lumen catheter according to the primary health-care provider's orders. 4. Turn the patient from side to side to promote output, which minimizes clot formation in the urine.
33. ANSWER: 1, 4, 5. Rationales: 1. Having the patient void one last time at the end of the 24-hour period and adding it to the large collection container completes the test. It accurately includes the urine being produced within the specified 24-hour period. 2. This urine is not discarded but is added to the volume being collected. The urine voided one last time at the end of the 24 hours completes the test. 3. The first voiding is discarded and then all additional urine voided, including the last voiding at 24 hours, is collected. Chapter 20 Urinary Elimination 645 4. Discarding the first voiding is the correct way to initiate a 24-hour urine test. If the first voiding is included, the urine volume will incorporate more hours of urine produced than what should be included in 24 hours. The test results will be altered by excessive amounts of constituents in the greater volume of urine collected. This test can test for levels of adrenocortical steroids, hormones, protein, and creatinine clearance. 5. All voided urine for 24 hours is collected and then stored in a large collection container. TEST-TAKING TIP: Identify opposite options. Options 1 and 2 are opposites. One of these options is correct and the other is a distractor. Options 3 and 4 are opposites. One of these options is correct and the other is a distractor.
33. A primary health-care provider orders a 24-hour urine test. Which actions should be implemented by the nurse when conducting this test? Select all that apply. 1. Have the patient void one last time at the end of the 24 hours and add it to the volume being collected. 2. Have the patient void one last time at the end of the 24 hours and discard the urine. 3. Collect the first voiding and then add the urine voided for the next 24 hours. 4. Discard the first voiding and then collect the urine for the next 24 hours. 5. Store the collected urine for 24 hours in a large collection container.
34. ANSWER: 3. Rationales: 1. Perineal hygiene is not necessary before implementing the procedure. However, washing the conducting gel from the abdomen and suprapubic area is necessary after completing the procedure. 2. The patient is placed in the supine position so that the lower abdomen and suprapubic areas are exposed. 3. This is accurate information. This is a painless noninvasive procedure that should cause no discomfort. 4. The transducer is applied 1.5 inches, not 4 inches, midline above the pubic bone, aiming the scan head toward the patient's coccyx for an accurate reading. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word essential in the stem sets a priority.
34. A nurse is caring for a patient with a history of experiencing residual urine after voiding. The nurse uses a bladder ultrasound scanner (BUS) to detect the amount of urine that remains in the bladder after the patient voids. What action should the nurse implement that is essential to this test? 1. Give perineal hygiene before the procedure is initiated. 2. Position the patient in the left lateral position for the duration of the procedure. 3. Explain that no discomfort will be experienced as the transducer is moved on the surface of the skin. 4. Place the scan head on the abdomen, four inches midline above the pubic bone, aiming the scan head toward the coccyx.
35. ANSWER: 1. Rationales: 1. Urinary retention may occur after the procedure due to urethral edema. 2. It is not uncommon to experience pink, not red, urine after the procedure. The instrumentation may irritate the mucosal lining of the urinary tract, resulting in minor bleeding. 3. It is not necessary to maintain bedrest for several days after the procedure. Bedrest may be encouraged on the day of the procedure because hypotension may occur immediately after the procedure. 4. The patient can resume a regular diet immediately after the procedure. The patient will be advised to increase fluid intake for several days. A large amount of dilute urine decreases dysuria, prevents stasis, and limits the accumulation of bacteria in the bladder.
35. A nurse is caring for a patient who is scheduled for a cystoscopy. Which information should the nurse include when teaching the patient about what to expect after the procedure? 1. Urinary retention may occur after the procedure. 2. Urine may be dark red initially after the procedure. 3. Bedrest is necessary for several days after the procedure. 4. A clear liquid diet generally is ordered for a few days after the procedure.
36. ANSWER: 6, 1, 2, 4, 3, 5. Rationales: 6. The first step is providing perineal hygiene and drying the penis thoroughly. A penis that is clean and free from debris and moisture reduces the risk of infection, skin breakdown, and nonadherence of the condom. 1. The second step ensures that the catheter does not compress the glans and that there is a 1- to 11/2-inch distance between the glans penis and the drainage tubing. These actions prevent pressure against the glans and tissue at the distal end of the penis. 2. The third step is applying the condom to the full length of the shaft of the penis. Holding the penis firmly, perpendicular to the abdomen, extends the penis and facilitates the unrolling of the condom down the shaft of the penis. 4. The fourth step is securing the condom to the shaft by grasping the penis and gently compressing it so that the entire condom comes into contact with the penal shaft. 3. The fifth step is taping the external adhesive strip over the condom in a spiral along the length of the shaft. Applying it in a spiral reduces the risk of obstructing circulation, which can occur when it is applied around the condom at the proximal end of the penis. 5. The last step in the procedure is hanging the urine collection bag on the bed frame below the level of the bladder.
36. A nurse is applying a condom urinary catheter. Place the following steps in the order in which they should be implemented. 1. Hold the penis and place the catheter beyond the glans, leaving at least a 1-inch space at the tip of the penis. 2. Unroll the condom along the full length of the shaft of the penis. 3. Wrap the external adhesive strip in a spiral along the shaft. 4. Secure the condom with gentle compression. 5. Hang the collection bag from the bed frame. 6. Provide perineal care and dry thoroughly.
37. ANSWER: 4. Rationales: 1. An irritated bladder is associated with urge, not stress, incontinence. 2. Returning to her exercise class will help her continue to lose weight because obesity is a contributing factor for stress incontinence; however, the information in another option is a more effective intervention that will improve the underlying cause of her problem. 3. Although a toileting program may help to keep the bladder less full just before exercise or other planned strenuous activity, it will not help prevent the underlying cause of stress incontinence. 4. The patient is experiencing stress incontinence, most likely due to weakened pelvic floor muscles as result of five pregnancies and obesity. Stress incontinence occurs when intra-abdominal pressure increases related to such activities as exercise, laughing, coughing, sneezing, bending, and lifting. Kegel exercises help to increase pelvic floor muscle tone and should help the patient regain control of urine. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word best in the stem sets a priority. Identify the clang associations. The word exercise in the stem and in options 2 and 4 are clang associations. Examine options 2 and 4 carefully.
37. A nurse is obtaining a health history from a patient. The patient states that she is embarrassed about episodes of incontinence when she sneezes or exercises and that she no longer attends an exercise program for this reason. She now walks several miles a day to lose the 50 lb she gained when pregnant with her fifth child. Based on this information, which nursing intervention will best help the patient to address the underlying cause of her lack of urine control? 1. Teach the patient foods to avoid that irritate the bladder mucosa. 2. Encourage the patient to return to her exercise class. 3. Engage the patient in a toileting program. 4. Teach the patient Kegel exercises.
38. ANSWER: 2. Rationales: 1. Decreased sweating, not diaphoresis, is associated with Ditropan. 2. The patient may experience the side effect of palpitations caused by the anticholinergic effects of Ditropan. 3. Gastric irritation is not associated with Ditropan. 4. Orange-colored urine is associated with the drug phenazopyridine (Pyridium), a urinary tract analgesic, not Ditropan. TEST-TAKING TIP: Identify words in the stem that indicate negative polarity. The words side effect in the stem indicate negative polarity. The question is asking, "What is not a therapeutic effect of oxybutynin?"
38. The nurse is caring for an older adult who is receiving oxybutynin (Ditropan) to reduce the occurrence of bladder spasms related to a UTI. For which side effect should the nurse assess the patient? 1. Diaphoresis 2. Palpitations 3. Gastric irritation 4. Orange-colored urine
39. ANSWER: 1. Rationales: 1. The urine specimen should be collected and contained following the principles of sterile technique. A sterile container will not introduce environmental microorganisms into the specimen. This ensures that the results of the culture and sensitivity reflect the microorganisms present in the patient's urinary tract. 2. Urine in this section of the urinary collection device may be as long as 1 hour old and, therefore, not current. The hourly urine section of the collection bag moves collected urine into the main portion of the urine collection container when it is lifted. Generally, it does not have its own port. 3. This is contraindicated because the urine in this section of a urinary collection device may be many hours old. 4. Urinary retention catheters and collection bags generally are designed as closed drainage systems so they cannot be separated; this avoids unnecessary separation of tubing that may permit introduction of pathogenic microorganisms. TEST-TAKING TIP: Identify the unique option. Option 1 is unique. Options 2, 3, and 4 all relate to the removal of urine from the drainage system. Option 1 is the only option that contains an intervention that is performed after the urine is actually collected.
39. A nurse is caring for a patient with an indwelling urinary retention catheter. The primary health-care provider orders a urine specimen for culture and sensitivity. What should the nurse do when collecting this specimen? 1. Place the urine specimen in a sterile urine container. 2. Obtain the urine specimen from the hourly urine chamber of the collection bag. 3. Collect the urine specimen from the drainage port at the bottom of the collection bag. 4. Take the urine specimen directly from the distal end of the catheter after separating it from the tubing.
4. ANSWER: 1. Rationales: 1. This statement is true. The shorter urethra in woman makes them more susceptible to bladder infections than men who have a longer urethra. Also, the female urinary meatus is close to the anus, which increases the risk of transmission of microorganisms from the intestinal tract to the urinary meatus. 2. Retained urine associated with aging becomes more alkaline, not acidic, which is an ideal site for bacterial growth. 3. This should not be an issue as long as a woman cleanses the perineal area when bathing daily. 4. Frequent, not infrequent, sexual intercourse predisposes women to bladder infections. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority.
4. A nurse is caring for an older adult female who says, "Why am I always getting bladder infections?" Which response by the nurse is most appropriate? 1. "Women have a shorter urethra than men do, and that makes women more susceptible than men to bladder infections." 2. "Older adults may experience retained urine, which becomes more acidic and promotes the development of bladder infections." 3. "It is hard for women to cleanse the urinary meatus, which increases the risk of bladder infections." 4. "Infrequent sexual intercourse predisposes women to bladder infections."
Answer: 1. Rationale: The catheter in the vagina is contaminated and cannot be reused. If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus does not indicate that another nurse is needed although sometimes a second nurse can assist in visualizing the meatus (option 2).
4. The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action? 1. Leaves the catheter in place and gets a new sterile catheter. 2. Leaves the catheter in place and asks another nurse to attempt the procedure. 3. Removes the catheter and redirects it to the urinary meatus. 4. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus.
4. What should the nurse include in the plan of care for a patient in order to best prevent the cardiovascular complications associated with chronic renal failure? Answer: Restrict fluid and salt intake.
4. What should the nurse include in the plan of care for a patient in order to best prevent the cardiovascular complications associated with chronic renal failure? • Apply a nondrying lotion to the skin. • Maintain a low-fat, low-carbohydrate diet. • Evaluate ankles for edema daily. • Restrict fluid and salt intake.
40. ANSWER: 5, 4, 3, 2, 1. Rationales: 5. Milking the catheter should be performed first after it was observed that the patient did not void over a 2-hour period. This action will push sediment and mucus toward the collection bag and reestablish patency of the tube. 4. Palpating the patient's bladder should be done after establishing patency of the catheter. This will determine if the bladder is distended. 3. Encouraging the patient to drink fluids should be done after essential actions are implemented. Drinking fluids will increase the glomerular filtrate and increase the urinary output. 2. Continuing to observe the patient over the next hour may be done after actions have been taken to rectify the problem. Previous interventions may resolve the problem. 1. An order for irrigation should be obtained after other interventions have been attempted. This is an invasive intervention that should be left to last.
40. A nurse is caring for a 75-year-old male patient with an indwelling catheter. The nurse identifies that the patient has had no additional urine in the bag over a 2-hour period. Place the nurse's actions in the order in which they should be performed. 1. Obtain an order to irrigate the patient's catheter. 2. Continue to assess the patient over the next hour. 3. Encourage the patient to drink fluids. 4. Palpate over the patient's bladder. 5. Milk the patient's catheter.
5. ANSWER: 1. Rationales: 1. Swabbing the specimen port with an antiseptic swab is necessary to remove microorganisms from the port that may contaminate the specimen. In addition, it reduces the risk of introducing microorganisms into the closed urinary retention catheter and collection bag system. 2. Sterile gloves are not necessary to maintain sterility of the specimen. Clean gloves protect the nurse from the patient's blood and body fluids. 3. The urine collection container must be a sterile urine collection container, not the clean container used for specimens for unsterile urinalysis specimens. 4. The time of day a specimen is collected from a urinary retention catheter will not alter the sterility of the specimen.
5. A nurse is caring for a patient who has a urinary retention catheter. The primary health-care provider orders a urine culture and sensitivity. Which step ensures that the collected specimen is sterile? 1. Swab the specimen port with an antiseptic swab. 2. Don sterile gloves when obtaining the specimen. 3. Use a urinalysis container to collect the specimen. 4. Collect the specimen early in the morning before breakfast.
5. A patient has a neobladder created following a radical cystectomy due to bladder cancer. The nurse plans to teach the patient which technique to incorporate into the home management routine? Answer: Self-catheterization
5. A patient has a neobladder created following a radical cystectomy due to bladder cancer. The nurse plans to teach the patient which technique to incorporate into the home management routine? • Bladder irrigation • Kegel exercises • Self-catheterization • Stoma wafer change
Answer: 3. Rationale: Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (option 1). Intake of cranberry juice creates an environment that inhibits infection (option 2). Clean technique is appropriate for touching the exterior portions of the system (option 4).
5. Which statement indicates a need for further teaching of the home care client with a long-term indwelling catheter? 1. "I will keep the collecting bag below the level of the bladder at all times." 2. "Intake of cranberry juice may help decrease the risk of infection." 3. "Soaking in a warm tub bath may ease the irritation associated with the catheter." 4. "I should use clean technique when emptying the collecting bag."
6. A patient receiving hemodialysis tells the nurse that the worst part of the treatment is the severe leg cramps that he gets a few hours after the procedure. What is the best explanation of this problem for the nurse offer to this patient? Answer: "The leg cramps are caused by the extra water and salt that are being removed."
6. A patient receiving hemodialysis tells the nurse that the worst part of the treatment is the severe leg cramps that he gets a few hours after the procedure. What is the best explanation of this problem for the nurse offer to this patient? • "The leg cramps are a result of the blood transfusions that you receive." • "The leg cramps are due to an infection that will need to be treated." • "The leg cramps are caused by the extra water and salt that are being removed." • "The leg cramps are happening because you are not eating enough protein."
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6. A primary health-care provider prescribes nitrofurantoin (Macrodantin) 100 mg twice a day by mouth for a patient with a urinary tract infection. The pharmacy sends up unit dose packages labeled 25 mg per capsule. The primary nurse on the 12-hour day shift checks the medication drawer to ensure that there are enough capsules for the next 24 hours. How many tablets should be available for disbursement to th8e patient? Answer: capsules
Answer: 4. Rationale: The key phrase is "the urge to void." Option 1 occurs when the client coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option 2 occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option 3 is involuntary loss of urine related to impaired function.
6. During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate? 1. Stress Urinary Incontinence 2. Reflex Urinary Incontinence 3. Functional Urinary Incontinence 4. Urge Urinary Incontinence
6. The nurse explains to a patient with a possible kidney infection that his symptoms are due to the retroperitoneal location of the kidneys. The nurse is aware that further testing might be required to confirm the diagnosis because other structures that occupy this area include the: (Select all that apply.) Answers: Pancreas. Duodenum. Ureters
6. The nurse explains to a patient with a possible kidney infection that his symptoms are due to the retroperitoneal location of the kidneys. The nurse is aware that further testing might be required to confirm the diagnosis because other structures that occupy this area include the: (Select all that apply.) • Stomach. • Gallbladder. • Pancreas. • Duodenum. • Ureters.
Answer: 2 and 4. Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (option 4). Increased fluids decrease concentration and irritation (option 1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (option 3). Showers reduce exposure of area to bacteria (option 5).
7. A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply. 1. Limit fluids to avoid the burning sensation on urination. 2. Review symptoms of UTI with the client. 3. Wipe the perineal area from back to front. 4. Wear cotton underclothes. 5. Take baths rather than showers.
7. The nurse is explaining to a student the role that the kidneys play in regulating blood pressure. The nurse would include which statements in this explanation? (Select all that apply.) Answers: The kidneys release renin. The kidney reabsorbs sodium and water.
7. The nurse is explaining to a student the role that the kidneys play in regulating blood pressure. The nurse would include which statements in this explanation? (Select all that apply.) • The kidneys release renin. • The kidneys produce aldosterone. • The kidney reabsorbs sodium and water. • The kidneys activate vitamin D. • The kidneys produce erythropoietin.
7. ANSWER: 1. Rationales: 1. Anuria describes urine output of less than 100 mL in 24 hours. Anuria is associated with kidney disease or congestive heart failure; both can be life-threatening situations. 2. Dysuria refers to painful or difficult urination. Although this is serious and may be associated with infection or partial obstruction of the urinary tract, generally it is not as critical as another clinical manifestation. 3. Polyuria refers to excessive urination. Although serious and may be caused by excessive hydration, diabetes mellitus, diabetes insipidus, or kidney disease, generally it is not as critical as another clinical manifestation. 4. Nocturia is defined as awakening at night to void. Although a concern because it may be associated with excessive fluid intake and a variety of urinary tract and cardiovascular problems, it generally is not as critical as another clinical manifestation. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word most in the stem sets a priority.
7. While all of the following clinical manifestations are important to report to a primary health-care provider, which is most important? 1. Anuria 2. Dysuria 3. Polyuria 4. Nocturia
8. ANSWER: 4. Rationales: 1. Although encouraging an increase in oral fluid intake may be implemented, it does not immediately address the patient's need to void. Also, the patient's bladder already is moderately distended. 2. Stroking the inner aspect of the patient's thigh may stimulate sensory nerves and promote the micturition reflex. However, this action should not be the first intervention. 3. Although pouring warm water over the perineal area may stimulate voiding, it is not the first action the nurse should take. 4. Assuming an upright position for voiding uses gravity to move urine downward toward the urinary meatus. Also, it is the most common position that people use to urinate. Assuming this position psychologically may facilitate voiding. TEST-TAKING TIP: Identify the word in the stem that sets a priority. The word first in the stem sets a priority. Identify the clang association. The word void in the stem and voiding in option 4 is a clang association.
8. A patient reports concern about not having urinated in several hours. The patient reports the sensation of the need to void and has moderate abdominal distention. What should the nurse do first? 1. Encourage the patient to drink more fluid. 2. Stroke the inner aspect of the patient's thigh. 3. Pour warm water over the patient's perineal area. 4. Have the patient assume an upright position for voiding.
8. The nurse caring for a patient with a diagnosis of acute tubular necrosis is aware that which nursing measure is essential in the early detection of complications? Answer: Monitor daily weight and output.
8. The nurse caring for a patient with a diagnosis of acute tubular necrosis is aware that which nursing measure is essential in the early detection of complications? • Administer antimicrobials as ordered. • Catheterize for residual urine after each void. • Monitor daily weight and output. • Encourage fluid intake.
Answer: 2. Rationale: The ileal conduit and vesicostomy (options 1 and 4) are incontinent urinary diversions, and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (option 3). Cognitive Level: Analyzing.
8. The nurse will need to assess the client's performance of clean intermittent self-catheterization (CISC) for a client with which urinary diversion? 1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy
8. The patient is admitted to the emergency department with left flank pain. A health history reveals that there has been no trauma. A KUB is ordered. The nurse prepares the patient by: Answer: Explaining that he will need to lie flat on the table for the procedure.
8. The patient is admitted to the emergency department with left flank pain. A health history reveals that there has been no trauma. A KUB is ordered. The nurse prepares the patient by: • Starting an IV to administer contrast. • Assessing for allergy to shellfish. • Administering a tap water enema. • Explaining that he will need to lie flat on the table for the procedure.
9. ANSWER: 1, 2, 4, 5. Rationales: 1. Eggs increase urine acidity, which tends to inhibit the growth of microorganisms. 2. Meats increase urine acidity, which tends to inhibit the growth of microorganisms. 3. Apple juice does not increase urine acidity. Pathogenic microorganisms exist and multiply more readily in alkaline environments. 4. Cranberry juice increases urine acidity, which tends to inhibit the growth of microorganisms. 5. Whole-grain breads increase urine acidity, which tends to inhibit the growth of microorganisms.
9. A patient with a history of urinary tract infections asks the nurse for suggestions to limit their occurrence. Which should the nurse encourage the patient to ingest to inhibit the growth of microorganisms that can cause a bladder infection? Select all that apply. 1. Eggs 2. Meats 3. Apple juice 4. Cranberry juice 5. Whole-grain breads
9. The nurse is admitting a patient with a diagnosis of acute kidney injury. What symptoms does the nurse expect to be manifested by the patient? (Select all that apply.) Answers: Hypertension Anuria Anasarca
9. The nurse is admitting a patient with a diagnosis of acute kidney injury. What symptoms does the nurse expect to be manifested by the patient? (Select all that apply.) • Alkalosis • Hypertension • Polyuria • Anuria • Anasarca
Answer: 3. Rationale: Because the bladder muscles will not contract to increase the intrabladder pressure to promote urination, the process is initiated manually. Options 1, 2, and 4: To promote continence, bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles.
9. Which focus is the nurse most likely to teach for a client with a flaccid bladder? 1. Habit training: Attempt voiding at specific time periods. 2. Bladder training: Delay voiding according to a preschedule timetable. 3. Credé's maneuver: Apply gentle manual pressure to the lower abdomen. 4. Kegel exercises: Contract the pelvic muscles.
d. Urine output is measured to monitor your kidney function
A client is scheduled for thoracic surgery & is told by the surgeon that a Foley catheter will be placed. After the surgeon leaves the client says "why do I have to have a tube in my bladder if I am having chest surgery" the nurses best response is: a. You are likely to be incontinent b. We want you to rest after the surgery c. It allows for ease of obtaining urine specimens d. Urine output is measured to monitor your kidney function
d. Assist the client to the toilet or commode
A client with normal intake & no genitourinary or renal disease has not voided in 6 hours. The client reports the need to void & has moderate lower abdominal distention. What should the nurse do first? a. Encourage the client to drink more fluids b. Scan the bladder c. Pour warm water over the client's perineal area d. Assist the client to the toilet or commode
b. Void after having intercourse d. Urinate when the urge to void is perceived
A nurse is caring for a female client who has recurrent UTIs. What should the nurse teach the client to do? Select all that may apply. a. Wear nylon underpants b. Void after having intercourse c. Take a bath instead of a shower d. Urinate when the urge to void is perceived e. Wipe from back to front after a BM f. Perform Kegel exercises weekly
b. Check for kinks in the tubing
A nurse notes that a clients Foley catheter has had no output for 3 hours. The first intervention that the nurse would perform is: a. Irrigate the Foley catheter b. Check for kinks in the tubing c. Notify the MD d. Encourage fluid intake e. Remove the Foley catheter
a. Kegel exercises b. Habit training c. The double void technique e. Caffeine intake
A patients states that she "loses urine" when she coughs or laughs. Which of the following would be relevant to discuss? Select all that apply. a. Kegel exercises b. Habit training c. The double void technique d. Self catheterization e. Caffeine intake
