Incorrect Prep U- 240 Exam 3 Ch 36 Urinary Elimination
The nurse has an order to obtain a 24-hour urine from a client. Which of the following instructions would be accurate for collection of the specimen? a) "You will need to have a catheter inserted for this collection." b) "Start collecting the urine with the next time you urinate." c) "Discard your first urine and begin the collection after that." d) "Begin the collection when you first urinate in the morning."
"Discard your first urine and begin the collection after that." Explanation: The nurse would give the instructions to the client that the first urine would be discarded and collections of urine begin after that point. The urine is then collected for 24 hours and may need to be placed on ice or refrigerated. When the 24 hours is completed, the client would need to be asked to void, and the specimen collection is completed.
A nurse is assessing a client who is complaining of difficulty urinating. Which of the following would be a priority? a) Determining any pain when palpating the lower abdomen b) Palpating the bladder above the symphysis pubis c) Asking the client when he/she had last urinated d) Obtaining the bladder scanner to check the urine volume
Asking the client when he/she had last urinated Explanation: The nurse, in assessing the bladder, would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.
A nurse is assessing a client who is complaining of difficulty urinating. Which of the following would be a priority? a) Palpating the bladder above the symphysis pubis b) Asking the client when he/she had last urinated c) Determining any pain when palpating the lower abdomen d) Obtaining the bladder scanner to check the urine volume
Asking the client when he/she had last urinated Explanation: The nurse, in assessing the bladder, would first determine when the client last urinated. Once this information is known, the nurse would then want to palpate the bladder and lower abdomen. If unable to determine bladder fullness, the nurse would want to obtain the bladder scanner, if available, in order to assess urine volume in the bladder.
A nurse is planning interventions for a client to assist in establishing a normal voiding pattern. Which of the following measures should be included? a) Encourage the client to wait to void at least 30 minutes when the urge is felt. b) Explain to the client that privacy is not important with urination. c) Place the client on a schedule to void every 4 hours during the daytime hours. d) Assist the client to a normal voiding position when possible.
Assist the client to a normal voiding position when possible. Explanation: Maintaining a normal voiding pattern would involve having privacy whenever possible, voiding once the urge is felt, and not waiting to urinate. Being in a normal voiding position is important for men and women. The client would not be scheduled to urinate; many people do not have a routine schedule, but void intermittently
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? a) Stasis b) Infection c) Dehydration d) Blood
Blood Explanation: 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.
A client has been n.p.o. 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? a) Pale yellow b) Colorless c) Dark amber d) Tea colored
Dark amber Explanation: Urine may be dark amber or orange-brown if it is very concentrated secondary to a decreased fluid intake. Urine is lighter than normal if it is diluted. Foods or drugs can also alter the color of urine. Tea-colored or very dark urine is a sign of dehydration.
A nurse assessing an elderly patient finds that the patient has had four urinary tract infections in the past year. Which physiologic change of aging would the nurse suspect is the cause? a) Decreased bladder contractility b) Decreased bladder muscle tone c) Diminished ability to concentrate urine d) Neurologic weakness
Decreased bladder contractility Explanation: The nurse would suspect the client had decreased bladder contractility, which lead to the client having issues with urinary retention. Diminished ability to concentrate urine would be an issue with the kidney, not the urinary tract.
A nurse is caring for a client with an external condom catheter. What is a guideline for applying and caring for this type of catheter? a) Keep the tip of the tubing 2-3 inches (5 to 7.5 cm) beyond the tip of the penis. b) Wash the penis with antimicrobial soap and dry thoroughly. c) Fasten the condom securely enough to prevent leakage without constricting the blood vessels. d) Remove the catheter every 8 hours, or more often in humid weather.
Fasten the condom securely enough to prevent leakage without constricting the blood vessels. Explanation: Nursing care of a client with an external condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. In all cases, care must be taken to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1-2 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area
A client reports that he is often unable to retain urine until he locates a toilet because his mobility is decreased. The nurse should recognize the characteristics of what type of incontinence? a) Functional b) Stress c) Total d) Urge
Functional Explanation: The nurse should document the client's condition as functional incontinence when the client is unable to retain urine for some time after getting an urge to void. Stress incontinence can result in the loss of small amounts of urine when intra-abdominal pressure rises. Urge incontinence is the need to void, perceived frequently with a short-lived ability to sustain control of flow. Total incontinence is the loss of urine without any identifiable pattern.
A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours? a) Transient incontinence b) Stress incontinence c) Reflex incontinence d) Functional incontinence
Functional incontinence Explanation: Functional incontinence is urine loss caused by the inability to reach the toilet because of environmental barriers, physical limitations, or loss of memory or disorientation. Stress incontinence occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. Reflex incontinence is an emptying of the bladder without the sensation to void. Transient incontinence appears suddenly and lasts for 6 months or less.
A male patient is being transferred to the hospital from a long-term care facility with a diagnosis of dehydration and urinary bladder infection. His skin is also excoriated from urinary incontinence. Which nursing diagnosis is most appropriate for this patient? a) Risk for Urinary Tract Infection related to dehydration b) Impaired Skin Integrity related to functional incontinence c) Urinary Incontinence related to urinary tract infection d) Impaired Skin Integrity related to urinary bladder infection and dehydration
Impaired Skin Integrity related to urinary bladder infection and dehydration Explanation: Impaired Skin Integrity related to urinary bladder infection and dehydration would be the appropriate nursing diagnosis. The nursing concern is his excoriated skin that is a result of the urinary bladder infection and dehydration. Urinary Tract Infection is not a nursing diagnosis, rather a medical diagnosis. The impaired skin integrity is not related to functional incontinence. Urinary Incontinence is not a nursing diagnosis, rather a medical diagnosis.
A home care nurse visits a client diagnosed with depression who informs the nurse that he has been prescribed amitriptyline. What would the nurse include when educating the client about the effects of this medication? a) It causes urine to turn blue-green. b) It decreases glomerular filtrate rate. c) It decreases sensation of bladder fullness. d) It causes urinary retention.
It causes urine to turn blue-green. Explanation: The nurse should inform the client that amitriptyline turns the urine blue-green. The risk of urinary retention is increased with medications that have anticholinergic effects. Tricyclic antidepressants and antihistamines are examples of such drugs. Narcotics can decrease the sensation of bladder fullness and the glomerular filtration rate.
A nurse is caring for a client who is catheterized following a surgery of the prostate. When caring for the client, the nurse performs continuous bladder irrigation. Which intervention should the nurse perform when providing continuous bladder irrigation? a) Place the sterile solution on the bed. b) Empty the balloon with a syringe. c) Purge air from the tubing. d) Clean the urinary meatus.
Purge air from the tubing. Explanation: When providing continuous bladder irrigation, the nurse must purge the air from the tubing to ensure that no air enters the system. The nurse should hang the sterile irrigating solution from an IV pole, rather than place it on the bed, to allow it to flow freely. The nurse empties the balloon with a syringe. The urinary meatus is cleaned when removing the catheter, not during continuous bladder irrigation.
A nurse is performing an intermittent closed catheter irrigation on a client and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's response to this situation? a) Prepare to change the catheter. b) Repeat the irrigation. c) Notify the primary care provider. d) Wait 3 hours and repeat irrigation.
Repeat the irrigation. Explanation: If the tubing was not clamped before introducing the irrigation solution, the nurse should repeat the irrigation. If the tubing is not clamped, the irrigation solution will drain into the urinary drainage bag and not enter the catheter.
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? a) Stress incontinence b) Reflex incontinence c) Urge incontinence d) Functional incontinence
Stress incontinence Explanation: The nurse should document the client's condition as stress incontinence following weakening of perineal and sphincter muscle tone secondary to giving birth. Reflex incontinence is caused by damage to motor and sensory tracts in the lower spinal cord secondary to trauma. Urge incontinence is caused by bladder irritation secondary to infection. Functional incontinence is caused by impaired mobility, impaired cognition, or an inability to communicate.
Which is not true of urine color? a) The color of urine ranges from light yellow to amber. b) The appearance of urine streaked with blood is always abnormal. c) Someone's state of hydration affects the color. d) Medications can alter urine's color.
The appearance of urine streaked with blood is always abnormal. Explanation: Urine may appear cloudy, dark reddish-brown, or streaked with blood when a woman is menstruating.
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? a) The novice nurse observes the lower abdominal wall for any swelling. b) The novice nurse asks the client when was the last time he voided before palpating the bladder. c) The novice nurse measures the height of the edge of the bladder above the symphysis pubis. d) The novice nurse asks the client to urinate before palpating the bladder.
The novice nurse asks the client to urinate before palpating the bladder. Explanation: The urinary bladder cannot be palpated when empty, so the client should not urinate before the nurse palpates or percusses it. During data collection, the client should be asked when the last time he voided was, before the bladder is palpated. The height of the edge of the bladder should be measured above the symphysis pubis. The lower abdominal wall during an urinary bladder assessment is observed for any swelling
Which statements about suprapubic catheters is true? a) They are often preferred over an indwelling urethral catheter for long-term urinary drainage. b) Inadvertent dislodgement can permanently damage the urethra. c) They are surgically inserted through a small incision above the umbilicus. d) They drain urine directly from the ureters.
They are often preferred over an indwelling urethral catheter for long-term urinary drainage. Explanation: Suprapubic catheters are associated with: decreased risk of contamination with organisms from fecal material; elimination of damage to the urethra; a higher rate of client satisfaction; and a lower risk of catheter-associated urinary tract infections.
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? a) Functional incontinence b) Total incontinence c) Overflow incontinence d) Stress incontinence
Total incontinence Explanation: Total incontinence may be the result of surgery, trauma, or physical malformation; the client has continuous and unpredictable loss of urine. Stress incontinence is related to an increase in intra-abdominal pressure; and commonly occurs during activities, such as coughing and sneezing. Overflow incontinence is associated with overdistention and overflow of the bladder; and the signal to empty the bladder is lost, the bladder fills, and the client dribbles urine. Functional incontinence occurs because the client is unable to reach the toilet.
A woman is reporting bladder urgency. It is most important to assess: a) vitamin supplements. b) weight. c) caffeine intake. d) exercise.
caffeine intake. Explanation: Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.
During his stay in the hospital, a male client has established a pattern of maintaining urinary continence during the day, but he is experiencing incontinence at night. What intervention should the nurse implement in this client's care? a) indwelling catheter b) intermittent catheterization at bedtime c) toileting the client every 2 hours d) condom catheter
condom catheter Explanation: A condom catheter may be used in the care of male clients who lack voluntary control of urination. This is preferable to invasive catheterization (which presents an infection risk). Frequent toileting may prevent episodes of incontinence but would significantly disrupt the client's sleep quality.
A client at the health care facility has been diagnosed with total urinary incontinence. How could the nurse describe the condition of the client? a) loss of small amount of urine when intra-abdominal pressure rises b) loss of urine without any identifiable pattern or warning c) loss of urine control because a toilet is not accessible d) need to void is perceived frequently, with short-lived ability to sustain control of flow
loss of urine without any identifiable pattern or warning Explanation: The nurse could describe the client's condition as the loss of urine without any identifiable pattern or warning. Stress incontinence can be described as loss of a small amount of urine when intra-abdominal pressure rises. Urge incontinence can be described as the need to void being perceived frequently with a short-lived ability to sustain control of flow. Functional urinary incontinence can be described as the loss of control over urination because a toilet is not accessible.
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: a) pus. b) protein. c) calculi. d) casts.
pus. Explanation: Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI.
The doctor has ordered the collection of a fresh urine sample for a particular examination. Which urine sample would the nurse discard? a) the voiding collected at 4 p.m. b) the sample collected immediately after lunch c) the first voiding of the day d) the bedtime voiding
the first voiding of the day Explanation: The nurse would discard the first void of the day. The bladder has collected urine that has been produced by the kidneys overnight. The first voided urine of the day is usually more concentrated than other urine excreted during the day. Because the first urine of the day is not fresh, but rather an accumulation of a number of hours of kidney output, this urine may or may not be used as a specimen for certain tests. The other options would be appropriate to use for urine tests
Which situation warrants urinary catheterization? Select all that apply. a) A sterile urine specimen is needed from an acutely confused client. b) A client with an enlarged prostate is unable to void. c) A client is in septic shock and highly unstable. d) A client has developed a urinary tract infection. e) A client is unable to mobilize to the bathroom following abdominal surgery.
• A client is in septic shock and highly unstable. • A sterile urine specimen is needed from an acutely confused client. • A client with an enlarged prostate is unable to void. Explanation: Reasons for urinary catheterization include monitoring acutely ill clients, obtaining sterile urine specimens from clients who cannot otherwise provide them, and relieving urinary retention. The presence of a urinary tract infection does not necessarily indicate a need for catheterization. A client who is immobile should be introduced to the use of a bedpan or commode.
A nurse is caring for an older adult client who is incontinent. Which effects of aging might contribute to urinary alterations? (Select all that apply.) a) Altered thought processes may cause urinary frequency. b) Increased bladder motility decreases the incidence of urinary tract infections. c) Diminished ability of kidneys to concentrate urine may result in nocturia. d) Neuromuscular problems may interfere with voluntary control of urination. e) Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. f) Decreased bladder contractility may lead to urine retention and stasis.
• Diminished ability of kidneys to concentrate urine may result in nocturia. • Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine. • Decreased bladder contractility may lead to urine retention and stasis. • Neuromuscular problems may interfere with voluntary control of urination. Explanation: The effects of aging include the following: diminished ability of kidneys to concentrate urine, which may result in nocturia; decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination; decreased bladder contractility may lead to urine retention and stasis with increased risk of urinary tract infection; neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control of urination.
The nurse is catheterizing a male urinary bladder, and urine leaks out of the meatus around the catheter. What actions would the nurse perform next? (Select all that apply.) a) Consider an evaluation for urinary tract infection. b) If under fill is suspected, attempt to push the catheter further into the bladder. c) Increase the size of the indwelling catheter. d) Ensure that the correct amount of solution was used to inflate the balloon. e) Make sure the smallest sized catheter with a 10-mL balloon is used. f) Assess the patient for diarrhea.
• Make sure the smallest sized catheter with a 10-mL balloon is used. • Consider an evaluation for urinary tract infection. • Ensure that the correct amount of solution was used to inflate the balloon. Explanation: The nurse would make sure the smallest sized catheter with a 10-mL balloon is used for the procedure. Large catheters cause bladder and urethral irritation and trauma. Large, balloon-fill volumes occupy more space inside the bladder and put added weight on the base of the bladder. Irritation of the bladder wall and detrusor muscle can cause leakage. If leakage persists, consider an evaluation for urinary tract infection. Ensure that the correct amount of solution was used to inflate the balloon. Underfilling the balloon can cause the catheter to dislodge into the urethra. The nurse would not increase the size of the indwelling catheter. The nurse would not have a need to assess the client for diarrhea. The nurse would not attempt to push the catheter further into the bladder if under fill is suspected. This could cause trauma to the urethra or bladder of the client.
