Ch 37

The nurse is preparing to insert an indwelling urinary catheter into a female client's bladder. The nurse has opened the sterile catheterization tray using sterile technique, donned sterile gloves and has opened all sterile supplies. Arrange the following steps in the correct order. -Insert the lubricated catheter into the urethra. -Inflate the balloon with the correct amount of sterile saline. -Clean each labial fold, then the area directly over the meatus. -Discard used supplies. -Advance the catheter until there is a return of urine.

1. Clean each labial fold, then the area directly over the meatus. 2. Insert the lubricated catheter into the urethra. 3. Advance the catheter until there is a return of urine. 4. Inflate the balloon with the correct amount of sterile saline. 5. Discard used supplies.

A client 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?" -"Are you on any type of special diet at home?" -"How often do you have a bowel movement?" -"Are you on any blood pressure medications?"

-"How frequently do you urinate each day?" The client with frequent urinary tract infections may have infrequent urination, which can lead to stagnation of urine in the bladder; this potentially leads to growth of bacteria and a UTI. Taking blood pressure medication, being on a special diet, or having bowel movements do not increase the risk for urinary tract infections.

The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response? -"This is extremely abnormal. You will need to see your son's pediatrician." -"I would only worry about this if you were raising a daughter." -"It would be appropriate to place your son in incontinence undergarments." -"Let's review the types of fluids that your child drinks in the morning."

-"Let's review the types of fluids that your child drinks in the morning." Bladder irritants such as caffeine can cause urge incontinence; it is appropriate to determine whether the child is consuming fluids that contain caffeine. The child's urge incontinence is not extremely abnormal, and this physiological response is not related to gender. It is too soon to refer the client to the health care provider without taking a history, and it is impractical to simply recommend incontinence undergarments.

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? -"I agree; please make an appointment with your health care provider." -"This only happened one time, so it is nothing to worry about." -"Let's review your medication history and whether you consume bladder irritants." -"I suggest that you invest in incontinence undergarments."

-"Let's review your medication history and whether you consume bladder irritants." Urge incontinence can be aggravated by bladder irritants such as caffeine or alcohol, and can take place if diuretics are taken in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the health care provider, or to recommend incontinence undergarments.

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine? -24-hour specimen -clean-catch specimen -random specimen -intermittent specimen

-24-hour specimen A 24-hour urine specimen is required for accurate measurement of the kidney's excretion of substances that the kidney does not excrete at the same rate throughout the day. A clean-catch or midstream-voided specimen is used when a specimen relatively free from microorganisms is required. Random urine specimen collection is used when sterile urine is not required.

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. -Administer an IV on the arm high above the access site. -Perform venipuncture below the access site to obtain a blood sample for laboratory testing. -Measure the client's blood pressure on the arm above the access site.

-Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration. The nurse should auscultate over the hemodialysis access site with the bell of a stethoscope, listening for a bruit or vibration, to assess the patency of the access. The nurse should not measure the client's blood pressure, perform a venipuncture, or start an IV on the access arm, as doing so could lead to infection or clotting of the graft or fistula.

Which symptom will have a great impact on the extracellular fluid for water conservation? -Burns -Fracture -Small laceration -Pain

-Burns The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.

The nurse is working with a client who requires continence training. Which client teaching about pelvic floor muscle exercises (Kegel exercises) will the nurse include? -Loosen the internal muscles used to prevent or interrupt urination. -Keep muscles contracted for at least 10 seconds. -Relax muscles for at least 5 minutes between Kegels. -Perform these exercises two times daily for a week.

-Keep muscles contracted for at least 10 seconds. Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

A client who undergoes peritoneal dialysis is admitted to the hospital after an elective total-knee arthroplasty. Upon assessment the nurse visualizes redness, drainage, and odor to the area around the peritoneal dialysis catheter. Palpation of the abdomen causes the client pain. Which intervention is the priority? -Placing the client as N.P.O. status. -Obtaining laboratory studies. -Sitting the client up in a greater than a 40-degree angle. -Notifying the health care provider of the assessment findings.

-Notifying the health care provider of the assessment findings. The assessment is indicative of peritonitis or infection associated with the peritoneal dialysis catheter. The health care provider may request laboratory studies, but these cannot be obtained until a prescription is received. There is no indication to withhold oral food or fluids from the client at this time. Sitting the client up may aggravate the pain. The nurse should attempt to keep the client in the most comfortable position possible until a prescription is received from the health care provider.

While providing care to a client admitted to the health care facility, the client states that she has "a burning sensation when urinating." After further questioning, the nurse inspects the client's perineal area. Which sign/symptom would the nurse document as an abnormal finding? -Moist perineal skin -Reddened perineal skin -Presence of smegma -Absence of discharge

-Reddened perineal skin The presence of reddened perineal skin is an abnormal finding. The healthy skin should be moist and noninflamed with no discharge present. Smegma (an accumulation of white, odorous secretions from sebaceous glands found under the labia minora in women and under the foreskin in men) is considered a normal finding.

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 diameter of the catheter is too large. -The nurse failed to deflate the retention balloon after pretesting it for integrity. -The client has an occult abscess in the urethra.

-The client has an enlarged prostate. Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.

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

-True People with indwelling urinary catheters lose bladder tone because the bladder muscle is not being stretched by the bladder filling with urine. During prolonged periods of immobility, decreased bladder and sphincter tone can result in poor urinary control and urinary stasis. Other causes of decreased muscle tone include childbearing, muscle atrophy due to decreased estrogen levels as seen with menopause, and damage to muscles from trauma.

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? -Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. -Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. -Perform hand hygiene between cleansing the woman's labia and inserting the catheter. -Insert the catheter with her left hand while supporting the woman with her right hand.

-Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. Using the thumb and one finger of the nondominant hand, the nurse should spread the client's labia and identify the meatus. The nurse should be prepared to maintain separation of labia with one hand until the catheter is inserted and urine is flowing well and continuously. The nurse does not let go of the labia to perform hand hygiene after cleansing. The catheter is inserted with the dominant hand.

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? -reddish-brown, clear -clear, light yellow -dark brown, cloudy -aromatic, green

-dark brown, cloudy The client with advanced liver disease is expected to have dark brown or dark amber urine; infection may be represented by cloudy urine. Other answers are incorrect.

The nurse is inserting a urinary catheter into a female client and has begun to inflate the balloon, an action that has caused the client to wince and cry out in pain. Consequently, the nurse should: -deflate the balloon, insert the catheter further, and slowly attempt reinflation. -wait for 30 seconds, help the client to relax, and attempt inflation again. -stop, deflate the balloon, withdraw the catheter 0.75 to 1.5 in (2 to 4 cm), and slowly reinflate. -deflate the balloon, withdraw the catheter, and use a smaller sized catheter.

-deflate the balloon, withdraw the catheter, and use a smaller sized catheter. If the client reports pain during balloon inflation, the nurse should stop inflation of balloon, which is most likely still in the client's urethra. The nurse should withdraw the solution from the balloon, insert the catheter an additional 0.5 to 1 in (1.25 to 2.5 cm), and slowly attempt to inflate the balloon again. Re-attempting inflation in the same location or after slight withdrawal could cause trauma to the client's urethra. It is not necessary to utilize a smaller gauge catheter.

A client with a new urostomy requires teaching by the nurse. The nurse will construct the plan of care and education based upon which primary nursing diagnosis? Select all that apply. -risk for impaired skin integrity -stress urinary incontinence -risk for infection -situational low self-esteem -functional urinary incontinence

-risk for impaired skin integrity -risk for infection -situational low self-esteem The client with a new urostomy may be at risk for impaired skin integrity and infection if the client does not care properly for the ostomy. Therefore, the nurse will use these nursing diagnoses to plan care and education. The client may also experience a change in self-esteem due to this different way of elimination. The client will not experience types of incontinence, since the urostomy will continually drain urine.

Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)? -Foley catheter -suprapubic catheter -indwelling urethral catheter -straight catheter

-straight catheter Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. A suprapubic catheter is used for long-term continuous drainage. This type of catheter is inserted surgically through a small incision above the pubic area.

A client reports to the nurse that after delivering a baby, she loses small amounts of urine each time she sneezes or laughs hard. Which type of incontinence does the nurse anticipate? -urge -total -reflex -stress

-stress Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing. Urge incontinence takes place when there is a delay in accessing a toilet. Reflex incontinence takes place when a client automatically releases urine and cannot control it. Total incontinence takes place without a pattern or warning, and without client control.

When collecting a urine sample from a client for examination, the nurse notes that the sample appears reddish-brown in color. What could cause this variation in color of the urine? -dehydration -infection -stasis -blood

-blood A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.

The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify? -urinary tract infection (UTI) -urinary retention -urinary incontinence -urinary suppression

-urinary retention Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Urinary incontinence is the inability for the client to control his urine. There are many different causes for urinary incontinence. Urinary tract infections are a leading cause of morbidity and health care expenditures in persons of all ages, accounting for up to 40% of infections reported by acute care hospitals. These infections can be of the upper or lower urinary system. Urinary retention is the inability to urinate. The causes of urinary retention are numerous.