Chapter 37 Urinary Elimination
The nurse is collecting a clean-catch specimen from a client. Which nursing action is performed correctly in this procedure?
Position the container near the meatus, and collect at least 10 mL of urine
A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient's needs? Encouraging the use of bladder training exercises Providing assistance with toileting every 4 hours Positioning a bedside commode near the bed The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on a commode uses gravity to empty the bladder fully and thus prevents urinary stasis. Teaching the avoidance of fluids after 5 p.m. (Fluids may be decreased during the last 2 hours before bedtime, but they should not be avoided completely after 5 p.m. Some fluid intake is necessary for adequate renal perfusion).
Positioning a bedside commode near the bed
A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What action would be a priority when caring for this patient? Preventing the tubing from kinking to maintain free urinary drainage Not removing the sheath for any reason Fastening the sheath tightly to prevent the possibility of leakage Maintaining bedrest at all times to prevent the sheath from slipping off
Preventing the tubing from kinking to maintain free urinary drainage
A nurse reviews the results of a patient's urinalysis. Which constituent found in urine indicates the presence of an abnormality? Electrolytes Protein Water Urea
Protein- The presence of protein in the urine indicates that the glomeruli have become too permeable, which occurs with kidney disease. Most plasma proteins are too large to move out of the glomeruli, and the small proteins that enter the filtrate are reabsorbed by pinocytosis.
A nurse must obtain a urine specimen from a patient. Which nursing intervention is the greatest help to most people who need to void for a urine test? 1. Exerting manual pressure on the abdomen 2. Encouraging a backward rocking motion 3. Running water in the sink 4. Providing for privacy
Providing for privacy
A patient has urinary incontinence. Which is the best nursing intervention for this patient? Providing skin care immediately after soiling Using a deodorant soap when providing skin care Drying the area well after providing perineal care Dusting the perineal area with a light film of cornstarch
Providing skin care immediately after soiling
The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:
Pus
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?
Reddened perineal skin
Which urinary care teaching will the nurse provide to a young adult female client?
Refrain from douching unless ordered by a health care provider
Normal Urine: Red blood cells
0-4 per high power field
A patient's urine is cloudy, is amber, and has an unpleasant odor. Which problem may this information indicate that requires the nurse to make a focused assessment? Urinary retention Urinary tract infection. Ketone bodies in the urine High urinary calcium level
Urinary tract infection- The urine appears concentrated (amber) and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria).
The nurse is reviewing the chart of an older adult client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed?
Urine culture sensitivity - 100,000/mL
The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?
Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.
A nurse is caring for an older adult client at his home. The client has had a condom catheter applied. Which describes a condom catheter?
a flexible sheath that is rolled around the penis
A nurse is preparing a discharge teaching plan for a client being sent home with a peritoneal dialysis catheter in place. Which guideline should be included in the instructions?
The client should avoid wearing tight clothes or belts near the site.
A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?
The client will have to wear an external appliance to collect urine.
The nurse is collecting data on a client with reflex incontinence. Which information would the nurse ask the client during the physical assessment?
"Do you have the sensation to urinate?"
A 70-year-old client confides to the nurse that she is "terribly embarrassed" that she has developed urinary incontinence over the past year. Which nursing response supports the client's self-esteem?
"Let's explore structuring activities and toileting breaks."
A woman is reporting bladder urgency. It is most important to assess:
Caffeine intake
The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation?
Having the client sign a consent form for the procedure
A nurse assesses the urine of a client who is using a bedpan and finds that it is a dark brown color. What medication might be causing this effect?
Levodopa
A client who visits a health care facility for a routine assessment reports to the nurse being unable to control urinary elimination. This has resulted in the client soiling clothes and has led to a lot of embarrassment. Which nursing intervention will be appropriate to use with this client?
Regular toileting routine
The clinic nurse is collecting data from a female client with frequent, recurrent urinary tract infections who was discharged from the hospital. Which data collection would indicate to the nurse that the client is adhering to discharge instructions?
The client drinks two glasses of water before and after sexual intercourse.
Normal Urine: Bacterial
none
The nurse is providing care for an older adult admitted to the hospital with urinary retention. The client asks the nurse, "What is wrong with me?" Which is the best response by the nurse?
"As men age, the prostate enlarges over time."
A patient is reporting burning on urination. Which question should the nurse ask to best obtain information about the patient's dysuria? "Can you tell me about the problems you have been having with urination?" "How would you describe your experience with incontinence?" "What are your usual bowel habits?" "What color is your urine?"
"Can you tell me about the problems you have been having with urination?"
The nurse educator is presenting a lecture on clients at risk for developing urinary tract infections (UTIs). Which response made by the staff nurse would indicate to the educator a need for further teaching?
"Having sexual relationships does not put a woman at risk for developing a UTI."
The nurse caring for an older adult male client is determining whether the client can use a urinal to void. Which aspects of the client's medical history may contraindicate the use of a urinal?
The client is acutely confused and has been diagnosed with delirium.
A male client informs the nurse that he is concerned about dribbling and incontinence of small amounts of urine after the removal of an indwelling urinary catheter. The nurse is aware that the catheter was in place for 3 weeks prior to being removed. Which is the nurse's best response to the client?
"It will take a little while for the bladder to reestablish control as the strength of the muscle improves, and an accident is not unusual."
A parent asks the nurse when his 18-month-old daughter will be ready for toilet training. Which statement best answers the parent's question regarding toilet training?
"One signal of preparedness is when your child is dry for at least 2 hours."
A woman informs the nurse that when she is experiencing stress it is difficult to void, and wonders why this happens. What is the nurse's best explanation?
"Stress causes the muscles to become tense."
A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic). The patient questions the nurse: "My urine was bright orangish red today; is there something wrong with me?" What would be the nurse's best response? "This is a normal finding when taking phenazopyridine." "This may be a sign of blood in the urine." "This may be the result of an injury to your bladder." "This is a sign that you are allergic to the medication and must stop it."
"This is a normal finding when taking phenazopyridine."
The nurse is assessing a female client who states that she notices an involuntary loss of urine following a coughing episode. What would be the nurse's best reply?
"You are experiencing stress incontinence. Do you know how to do Kegel exercises?"
Normal Urine: White blood cells
0-5 per high power field
The client is preparing to obtain a clean-catch midstream urine specimen. Place in order the steps needed to complete the diagnostic test. Use all options.
1. Provide instruction to the client.2. Clean the area surrounding the urinary meatus with the provided cloth.3. Void a small amount into stool.4. Void into the provided collection device.5. Secure the lid on the specimen container.6. Submit collected specimen to the health care professional.
Normal Urine: Specific gravity
1.005 - 1.030
Normal Urine: Potential of hydrogen (pH)
4.6-8.0
A nurse caring for patients in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse screen for urinary retention? Select all that apply. A 78-year-old male patient diagnosed with an enlarged prostate An 83-year-old female patient who is on bedrest A 75-year-old female patient who is diagnosed with vaginal prolapse An 89-year-old male patient who has dementia A 73-year-old female patient who is taking antihistamines to treat allergies A 90-year-old male patient who has difficulty walking to the bathroom
A 78-year-old male patient diagnosed with an enlarged prostate A 75-year-old female patient who is diagnosed with vaginal prolapse A 73-year-old female patient who is taking antihistamines to treat allergies
A nurse is ordered to perform continuous irrigation for a patient with a long-term urinary catheter. What rationale would the nurse expect for this order? Irrigation of long-term urinary catheters is a routine order. Irrigation is recommended to prevent the introduction of pathogens into the bladder. A blood clot threatens to block the catheter. It is preferred to irrigate the catheter rather than increase fluid intake by the patient.
A blood clot threatens to block the catheter.
The nurse is caring for a postoperative client just returning from surgical insertion of a peritoneal dialysis catheter. Which are the nurse's priority assessments of the peritoneal dialysis catheter insertion site? Select all that apply.
Odor Pain Drainage Bleeding
Data must be collected to evaluate the effectiveness of a plan to reduce urinary incontinence in an older adult. Which information is least important for the evaluation process? The incontinence pattern State of physical mobility Medications being taken Age of the patient
Age of the patient
A nurse is caring for a client with an external condom catheter. Which guideline should be implemented when applying and caring for this type of catheter?
Fasten the condom securely enough to prevent leakage without constricting blood flow.
An older adult client is experiencing urinary retention. What age-related physiologic change does the nurse discuss with the client that may be a contributing factor?
Older adults may have a decrease in contraction of the bladder
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?
Anuria
A nurse is caring for a group of patients with a variety of urinary problems. Which patient's physical response should cause the most concern? Anuria Dysuria Diuresis Enuresis
Anuria
Nursing diagnosis:
Anxiety related to uncertainty of diagnostic testing outcomes and embarrassment secondary to discussion of female anatomy.
A nurse caring for a patient's hemodialysis access documents the following: "5/10/20 0930 AV fistula patent in right upper arm. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive bruit and thrill noted." Which documented finding would the nurse report to the primary care provider? Positive bruit noted. Area is warm to touch and edematous. Patient denies pain and tenderness. Positive thrill noted.
Area is warm to touch and edematous.
What nursing interventions should the nurse include in the Plan of Care to achieve the desired goals? Select all that apply. Answer all client questions. Assess client's level of anxiety. Complete the procedure as quickly as possible. Demonstrate equipment when possible. Provide privacy for the client by keeping them covered when possible. Explain all aspects of the procedure. Use only medical terminology. Use simple terminology.
Assess client's level of anxiety. Demonstrate equipment when possible. Provide privacy for the client by keeping them covered when possible. Explain all aspects of the procedure. Use simple terminology.
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?
Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.
The client has had three urinary tract infections in the last 6 months. What additional assessment procedures and diagnostic tests would be most helpful in determining the cause of recurrent infections? Select all that apply.
Bladder scanning after voiding Computerized tomograms of kidney (assess for obstruction, kidney stone or anatomical abnormalities causing a disruption in full bladder emptying) Urine culture XRay Kidney, Ureters, Bladder (KUB assesses size, shape and position of kidneys and abnormalities of the urinary system. It is often useful in the detection of obstruction by kidney stones as well).
The health care provider notifies a client of a diagnosis of glycosuria. Which additional assessment information will the nurse obtain from the client next?
Blood sugar
Which should a nurse teach the patient to avoid to prevent urinary diuresis? Select all that apply. 1. _____Narcotics 2. _____Caffeine 3. _____Activity 4. _____Alcohol 5. _____Protei
Caffeine Alcohol
The nurse is teaching an older adult female client who must provide a urine specimen. Which is the proper method to instruct the client to use to obtain a clean-catch urine specimen?
Catch the urine while holding the labia apart, after allowing the first urine to flow into the toilet.
The nurse is preparing to irrigate a Foley catheter. What is the nurse's initial action?
Check electronic health record for medical order.
When preparing to irrigate a Foley catheter, which is the appropriate initial nursing action?
Check health record for provider's order
A client is preparing to give a clean-catch specimen. What action should the nurse have the client do first?
Clean each side of the urinary meatus with a separate wipe.
Normal urine: Clarity
Clear
Goal:
Client will verbalize increased understanding of all procedures.
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?
Cloudy, foul odor
Normal Urine: Color
Colorless to yellow
A client has burning upon urination. The urinalysis indicates pyuria. Which is the next action the nurse will take?
Contact the health care provider
A patient is experiencing bladder irritability. Which fluid should the nurse teach the patient to include in the diet? Beer Coffee Orange juice Cranberry juice
Cranberry juice
During your assessment of a patient with UTI Symptoms which of the following is most likely to be seen? Dark Pink colored urine Bright red urine Dark amber Cloudy urine Light Yellow urine Port wine colored urine
Dark amber Cloudy urine
A client with a history of advanced liver disease comes to the emergency department (ED) with dehydration. White blood cell count shows elevation in bands and neutrophils. When preparing to catheterize the client, what color urine does the nurse anticipate will drain?
Dark brown, cloudy
A patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output? Decreased and highly concentrated Decreased and highly dilute Increased and concentrated Increased and dilute
Decreased and highly concentrated
Nursing diagnosis:
Deficient knowledge regarding diagnostic procedures.
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, withdraw the catheter, and use a smaller sized catheter
An older adult client informs the nurse that they are experiencing urinary incontinence. The client has no other health problems, and states, "I don't want anybody to know about this problem." How will the nurse promote the client's self-esteem?
Discuss the use of protective undergarments to avoid embarrassment from incontinence.
A nurse is performing a physical assessment on a newly admitted patient. Which problem identified by the nurse is often associated with urinary incontinence? Chronic pain Reduced fluid intake Disturbed self-esteem Insufficient knowledge
Disturbed self-esteem
A nurse is preparing a brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include? Select all that apply. Wear underwear with a synthetic crotch Take baths rather than showers Drink 8 to 10 8-oz glasses of water per day Drink a glass of water before and after intercourse and void afterward Dry the perineal area after urination or defecation from the front to the back Observe the urine for color, amount, odor, and frequency
Drink 8 to 10 8-oz glasses of water per day Dry the perineal area after urination or defecation from the front to the back Observe the urine for color, amount, odor, and frequency
A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply.
Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse.Wear underwear with a cotton crotch.Avoid clothing that is tight and restrictive on the lower half of the body.
When planning care for a client with a Foley catheter, which actions should the nurse include? Select all that apply.
Encourage fluid intake, unless contraindicated. Record volume and character of the urine. Maintain a closed urinary catheter system.
Which is an effective nursing intervention to prevent urinary tract infections? Teach female patients to wipe from the back to the front after urinating. Advise patients to report burning on urination to health-care providers. Instruct patients to use bath powder to absorb perineal perspiration. Encourage patients to drink several quarts of fluid daily.
Encourage patients to drink several quarts of fluid daily.
The nurse is performing a portable bladder ultrasound on a client who has palpable bladder distention. The scanner reveals little urine in the bladder. What should the nurse do next?
Ensure proper positioning of the scanner head and rescan.
Which information about a patient is communicated when a nurse documents that the patient has polyuria? Excreting excessive amounts of urine Experiencing pain on urination Retaining urine in the bladder Passing blood in the urine
Excreting excessive amounts of urine
A urinalysis has been ordered for a client. When is the best time for the client to provide a urine sample?
First thing in the morning
A nurse must measure the intake and output (I&O) of a patient who has a urinary retention catheter. Which equipment is most appropriate to use to measure urine output from a urinary retention catheter accurately? Urinal Graduate cylinder Large syringe Urine collection bag
Graduate cylinder- A graduate is a collection container with volume markings usually at 25-mL increments that promote accurate measurements of urine volume.
The nurse is caring for a client who had an arteriovenous (AV) graft surgically placed. The client is preparing for discharge. Which actions should the nurse teach the client to avoid? Select all that apply.
Having blood pressure measurements in the affected arm Getting venipuncture in the affected arm Carrying heavy items including purses or luggage with the affected arm Sleeping with the affected arm under the head or body
After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding? Pouring warm water over the patient's fingers. Having the patient ignore the urge to void until her bladder is full. Using a warm bedpan when the patient feels the urge to void. Stroking the patient's leg or thigh.
Having the patient ignore the urge to void until her bladder is full.
After surgery, a patient is having difficulty voiding. Which nursing action would most likely lead to an increased difficulty with voiding?Pouring warm water over the patient's fingers. Having the patient ignore the urge to void until her bladder is full. Using a warm bedpan when the patient feels the urge to void. Stroking the patient's leg or thigh.
Having the patient ignore the urge to void until her bladder is full.
The experienced nurse is observing a new nurse who is preparing to catheterize a female client. Which statement by the new nurse requires immediate intervention by the experienced nurse?
I will use clean gloves to handle the catheter and other equipment.
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?
Intermittent urethral catheter
What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?
It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.
The nurse is attempting to insert a urinary catheter into a female client's bladder and realizes the catheter has been inserted into the vagina. Which action is most appropriate?
Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
A nurse is caring for a female client who is unable to transfer to a commode. The nurse is assisting the client with positioning on a bedpan. Which statement should guide the nurse's action?
Many clients find it embarrassing or degrading to use a bedpan.
A nurse is caring for a patient diagnosed with bladder cancer who has a urinary diversion. Which actions would the nurse take when caring for this patient? Select all that apply. Measure the patient's fluid intake and output. Keep the skin around the stoma moist. Empty the appliance frequently.Report any mucus in the urine to the primary care provider. Encourage the patient to look away when changing the appliance. Monitor the return of intestinal function and peristalsis.
Measure the patient's fluid intake and output. Empty the appliance frequently.Report any mucus in the urine to the primary care provider. Monitor the return of intestinal function and peristalsis.
During a health history interview, a male client tells the nurse that he does not feel that he completely empties his bladder when he voids. The client has been diagnosed with an enlarged prostate. Which should the nurse include in the client education to encourage urination? Select all that apply.
Meditate while urinating Do Kegel exercises 3 to 5 times per day Try double voiding Avoid antihistamines Do not delay urination
Normal Urine: Bilirubin
Negative
Normal Urine: Blood
Negative
Normal Urine: Glucose
Negative
Normal Urine: Ketones
Negative
Normal Urine: Leukocyte esterase
Negative
Normal Urine: Nitrite
Negative
Normal Urine: Protein
Negative
Normal Urine: Urobilinogen
Negative
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?
Notifying the health care provider of the assessment findings
A client with an emergently placed central venous catheter (CVC) is to have emergent hemodialysis. Upon assessment of the CVC the nurse visualizes redness, drainage, and odor to the area around the CVC. Palpation of the surrounding skin causes the client pain. Which intervention is the priority?
Notifying the health care provider of the assessment findings
A nurse is caring for an older adult client who has been prescribed a condom catheter. What potential problems related to the use of a condom catheter should the nurse monitor in the client? Select all that apply.
Restricted blood flow to the glans tissue Excoriation of the skin in the glans area Kinks in tubing that encourage backflow of urine
Which assessment is not related to monitoring both urine and stool? Constituents Urgency Shape Color
Shape- Only stool can be assessed regarding shape. Stool usually is tubular in shape. Urine is a liquid that assumes the shape of the container in which it is collected
Which catheter would the nurse use to drain a client's bladder for short periods (5 to 10 minutes)?
Straight catheter
A 70-year-old client who has four children and six grandchildren states that she "wets" herself when she sneezes or laughs. She reports that sometimes this also occurs when rising from a sitting to standing position. Which type of incontinence does the nurse anticipate?
Stress
A nurse is caring for an alert, ambulatory, older resident in a long-term care facility who voids frequently and has difficulty making it to the bathroom in time. Which nursing intervention would be most helpful for this patient? Teach the patient that incontinence is a normal occurrence with aging. Ask the patient's family to purchase incontinence pads for the patient. Teach the patient to perform PFMT exercises at regular intervals daily. Insert an indwelling catheter to prevent skin breakdown.
Teach the patient to perform PFMT exercises at regular intervals daily.
The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?
The birth can cause perineal swelling.
A nurse is assisting a client with the use of a bedpan. The nurse understands that which statement about bedpans is true?
The largest part of a regular bedpan should be placed under the client's buttocks.
The health care provider has ordered an indwelling catheter inserted in a hospitalized male patient. What consideration would the nurse keep in mind when performing this procedure? The male urethra is more vulnerable to injury during insertion. In the hospital, a clean technique is used for catheter insertion. The catheter is inserted 2 to 3 in into the meatus. Since it uses a closed system, the risk for UTI is absent.
The male urethra is more vulnerable to injury during insertion.
The novice nurse is assessing the urinary bladder of a client with transient urinary incontinence. The nurse mentor would intervene if which action by the novice nurse is noted?
The novice nurse asks the client to urinate before palpating the bladder.
A nurse caring for patients in a long-term care facility is often required to collect urine specimens from patients for laboratory testing. Which techniques for urine collection are performed correctly? Select all that apply. The nurse catheterizes a patient to collect a sterile urine sample for routine urinalysis. The nurse collects a clean-catch urine specimen in the morning from a patient and stores it at room temperature until an afternoon pick-up. The nurse collects a sterile urine specimen from the collection receptacle of a patient's indwelling catheter. The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.
The nurse collects about 3 mL of urine from a patient's indwelling catheter to send for a urine culture. The nurse collects a urine specimen from a patient with a urinary diversion by catheterizing the stoma. The nurse discards the first urine of the day when performing a 24-hour urine specimen collection on a patient.
The nurse is caring for a client who has a history of renal failure. What is an accurate step when caring for the client's hemodialysis access?
The nurse should auscultate over the access site with the bell of the stethoscope, listening for a bruit or vibration, and palpate over the access site, feeling for a thrill or vibration. If these are not present, the health care provider should be notified at once. An IV should not be started in the arm with the access.
A nurse is ordered to catheterize a patient following surgery. Which nursing guideline would the nurse follow? The nurse would use different equipment for catheterization of male versus female patients. The nurse should use the smallest appropriate indwelling urinary catheter. The nurse should always sterilize the equipment prior to insertion. The nurse should choose a 12F, 5-mL or 10-mL balloon, unless ordered otherwise.
The nurse should use the smallest appropriate indwelling urinary catheter.
The nurse is caring for a client with a Foley catheter in place who has a prescription for a sterile urine specimen for culture and sensitivity. The nurse implements which techniques to obtain the prescribed urine specimen? Select all that apply.
The nurse uses a syringe to withdraw urine from the port.• The nurse dons clean gloves and cleanses the port with aseptic solution.
A confused patient is incontinent of urine and stool and smears the stool on the bed linens and bed rails. Which should be the initial patient goal? The patient will be clean and dry continuously The patient will become continent within a week. The patient will stop soiling the environment immediately. The patient will call for the bedpan whenever the urge to eliminate occurs.
The patient will be clean and dry continuously
A nurse is changing the stoma appliance on a patient's ileal conduit. Which characteristic of the stoma would alert the nurse that the patient is experiencing ischemia? The stoma is hard and dry. The stoma is a pale pink color. The stoma is swollen The stoma is a purple-blue color.
The stoma is a purple-blue color.
The nurse is teaching a client how to perform pelvic floor muscle exercises (Kegel exercises). Which teaching will the nurse include?
Tighten the internal muscles used to prevent or interrupt urination.
The nurse is caring for a client with concerns of urinary incontinence. A review of the client's data collection reveals the client has a history of spinal surgery and states, "I urinate all the time and cannot predict when I will urinate." This data collection would suggest to the nurse that this client is experiencing which type of urinary incontinence?
Total incontinence
T or F Use of an indwelling urinary catheter leads to the loss of bladder tone
True
A nurse is assisting a client with the use of a urinal. The nurse recognizes that which statement about the use of a urinal is true?
Unless contraindicated, nurses should encourage clients to stand to use a urinal.
The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify?
Urinary retention
The client has [choice from column 1] most likely caused by choice from (column 2). Column 1 urinary retention pyelonephritis overdistended bladder bladder tumor obstruction to urine flow Column 2 advanced age dehydration chronic kidney disease congenital kidney disorder congenital kidney disorder
Urinary retention Advanced age
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?
blood
A client has been NPO. after midnight for surgery. It is 11 a.m. and the nurse has asked her to void before being transferred to the surgical suite. The nurse should expect her urine to be what color?
dark amber
The nurse is caring for a client who has dark amber, strongly aromatic urine with nausea and vomiting. Which condition does the nurse anticipate?
dehydration
Normal Urine: Squamous epithelial
none
The nurse has entered a client's room to empty the client's urine collection bag at the end of a busy shift. The nurse realizes that the client's urine output is 75 mL over the past 8 hours. The nurse would recognize that the client is experiencing:
oliguria.
A nurse is caring for a client who has an infant age 4 months. The client informs the nurse that she has been experiencing a sudden loss of urine whenever she laughs; this is causing embarrassment to her. Which type of urinary incontinence is this client experiencing?
stress incontinence
The nurse is caring for a client who has been experiencing nausea, vomiting, and diarrhea for 3 days. Which urine characteristics does the nurse anticipate?
strongly aromatic, dark amber
