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Ch. 36 Urinary Elimination

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created 1 year ago by jamielgladden
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1

A nurse performing continuous bladder irrigation on a client notes that hourly drainage is less than amount of irrigation being given. Which interventions would be appropriate in this situation? Select all that apply.
a)If return flow remains decreased, notify the physician.
b)Lower the bag 3 to 6 inches (7.5-15 cm) and recheck the client.
c)Roll the client onto his back
d)Palpate for bladder distention.
e)Check to make sure that the tubing is not kinked.
f)Remove the catheter in place.

If return flow remains decreased, notify the physician.
• Lower the bag 3 to 6 inches (7.5-15 cm) and recheck the client.
• Palpate for bladder distention.
• Check to make sure that the tubing is not kinked.
The nurse should palpate for bladder distention; if client is lying supine, roll the client onto his side to help increase the amount of drainage. The nurse should also check to make sure that the tubing is not kinked and if return flow remains decreased, notify the physician.

2

A client is suspected of having a disease process affecting the functional unit of the kidney. Which stucture is most likely involved?
a)Glomerulus
b)Nephron
c)Loop of Henle
d)Bowman's capsule

Nephron

The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman’s capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman’s capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters

3

When a client is diagnosed with a urinary tract infection, the nurse anticipates that the client's urine will be:
a)greenish with a strong ammonia odor.
b)cloudy with an offensive odor.
c)transparent with an aromatic odor.
d)light yellow with a faint ammonia odor.

cloudy with an offensive odor.

A strong, offensive odor is not normally present in urine that is free of infection.

4

Which is not true of urine color?
a)Someone's state of hydration affects the color.
b)The color of urine ranges from light yellow to amber.
c)The appearance of urine streaked with blood is always abnormal.
d)Medications can alter urine's color.

The appearance of urine streaked with blood is always abnormal.

Urine may appear cloudy, dark reddish-brown, or streaked with blood when a woman is menstruating

5

A woman is reporting bladder urgency. It is most important to assess:
a)caffeine intake.
b)weight.
c)vitamin supplements.
d)exercise.

caffeine intake.

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

6

Several of the clients on a geriatric subacute medicine unit are experiencing urinary incontinence from differing causes. Which statement suggests that the client requires further education?
a)"At home, I take my water pill in the morning so that I don't have to use the bathroom as much during the night."
b)"I make sure to limit how much I drink so that I don't have accidents."
c)"I know it's hard to get there, but I want to try to use the commode instead of wearing an adult diaper."
d)"I've made a point of scheduling when I drink water instead of waiting until I'm thirsty."

"I make sure to limit how much I drink so that I don't have accidents."

Limiting fluid intake is not a healthy practice, and clients should be encouraged not to use fluid restriction as an incontinence management strategy. Promoting fluid intake is beneficial for most clients who do not possess a contraindication, and it is appropriate and useful to take diuretics in the morning to avoid nocturia. Even though it may involve work for both the client and the nurse, clients who want to use a bathroom or commode rather than an adult absorbent brief should be encouraged to do so

7

Which is true regarding the normal urination?
a)Urinary output does not vary all that much between adults and children.
b)Catheterized clients should drain a minimum of 30 mL of urine per hour.
c)In adults, the amount of urine voided typically does not depend on fluid intake and losses.
d)In adults, the average amount of urine per void is 500 mL.

Catheterized clients should drain a minimum of 30 mL of urine per hour.

Urine output of less than 30 mL per hour may indicate inadequate blood flow to the kidneys. In adults, the average amount of urine per void is approximately 200 to 400 mL. Adults generally have a urine output of 1500 mL per day, while children, depending on age, have a urine output between 500 and 1500 mL per day. Urine output can vary greatly, depending on intake and fluid losses.

8

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?
a)“You are experiencing transient incontinence. Have you been administered diuretics or IV fluids lately?”
b)“You are experiencing stress incontinence. Do you know how to do Kegel exercises?”
c)“You are experiencing total incontinence. Have you had any surgeries or trauma that may be causing this?”
d)“You are experiencing reflex incontinence. Have you had a spinal cord injury in the past?”

“You are experiencing stress incontinence. Do you know how to do Kegel exercises?”

Stress incontinence occurs when there is an involuntary loss of urine related to an increase in intra-abdominal pressure. This commonly occurs during coughing, sneezing, laughing, or other physical activities. Childbirth, menopause, obesity, or straining from chronic constipation can also result in urine loss. Pelvic floor muscle training (PFMT) can improve voluntary control of urination and significantly reduce or eliminate problems with stress incontinence by strengthening perineal and abdominal muscle tone (Huebner et al., 2011). PFMT, more commonly called Kegel exercises, targets the inner muscles that lie under and support the bladder. These muscles can be toned, strengthened, and actually made larger by a regular routine of tightening and relaxing. Transient incontinence appears suddenly and lasts for 6 months or less. It is usually caused by treatable factors, such as confusion secondary to acute illness, infection, and as a result of medical treatment (e.g., use of diuretics, IV fluid administration). Total incontinence is a continuous and unpredictable loss of urine, resulting from surgery, trauma, or physical malformation. Urination cannot be controlled due to an anatomic abnormality.

9

A client with frequent urinary tract infections (UTIs) has returned to the ambulatory clinic with symptoms of another UTI. The nurse reviews measures to follow to promote health and decrease the risk of contracting a UTI. Which measure is appropriate for the client to follow?
a)Drink two glasses of water before and after sexual intercourse.
b)Take baths instead of showers.
c)Wipe the perineal area from the rectal area to the urethra.
d)Wear satin or silk underwear that hugs the skin tightly.

Drink two glasses of water before and after sexual intercourse.

Measures to decrease the risk for a UTI include drinking ten 8-ounce glasses of water daily; observing for signs and symptoms of a UTI; drying the perineal from the urethra toward the rectum; drinking two glasses of water before and after sexual intercourse; showering rather than bathing; wearing cotton underwear; avoiding tight, constricting clothing; and drinking cranberry or blueberry juice daily.

10

The nurse is providing education to a client who is being discharged to home with an indwelling urinary catheter in place. What information is important for the nurse to discuss with the client?
a)Empty the catheter bag every few days when it is full.
b)Clamp the catheter tubing daily for 2 hours and then release the clamp at night.
c)Restrict daily fluid intake.
d)The catheter can be connected to a smaller leg bag for ambulation.

The catheter can be connected to a smaller leg bag for ambulation.

Educational points related to an indwelling urinary catheter include instructions on connecting the catheter to a smaller leg bag for ambulation; maintaining adequate fluid intake; keeping the catheter free of kinks (avoid clamping the catheter tubing); emptying the drainage bag at regular intervals; and avoiding a full drainage bag that may lead to reflux of urine.

11

The nurse is preparing a client for a cystoscopy procedure. Which intervention would be part of the preparation for this?
a)Maintaining the client without liquids before the procedure
b)Having the client sign a consent form for the procedure
c)Inserting a Foley catheter the morning of the procedure
d)Explaining to the client that the procedure will be painful

Having the client sign a consent form for the procedure

The client would sign a consent form for the procedure since it is invasive. This would be completed after the procedural health care provider had explained the purpose, risks, and benefits of the procedure. The client would not be maintained NPO (nothing by mouth) or have a catheter inserted for this procedure. The procedure is usually painless, so the client would not be told to expect pain as a normal part of the procedure.

12

A sterile urine specimen for culture and sensitivity has been ordered for a client who has an indwelling urinary catheter. How should the nurse obtain this specimen?
a)Empty the collection bag, wait 30 minutes, and then collect the contents of the collection bag.
b)Collect a urine specimen from the collection bag first thing in the morning, or a few hours after the client receives a diuretic.
c)Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.
d)Discontinue the indwelling catheter and insert an intermittent catheter to obtain the sterile specimen.

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

When it is necessary to collect a urine specimen from a client with an indwelling catheter, it should be obtained from the catheter itself using the special port for specimens. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. A client's catheter would not be removed for the sole purpose of obtaining a urine specimen.

13

A nurse is the guest speaker at a women's club. Most of the women are over the age of 40 years. The women have asked the nurse to speak on health promotion topics. In the area of urinary urgency, the nurse will instruct the women to:
a)increase caffeine daily.
b)limit fluid intake.
c)perform Kegel exercises.
d)take an antispasmodic.

perform Kegel exercises.

Pelvic floor exercises or Kegel exercises strengthen the pubococcygeal muscles and effectively promote urinary control.

14

The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?
a)“Void into the specimen hat in the toilet bowl.”
b)“You will have a catheter put in to collect the urine.”
c)“Save all urine for the next 24 hours.”
d)“Void a small amount, stop, and discard it.”

“Void a small amount, stop, and discard it.”

When collecting a midstream urine specimen, the client voids a small amount, stop, and discards it; the first small amount helps to flush away organisms near the urinary meatus. The midstream urine specimen is a sterile specimen so it is not collected in the hat in the toilet bowl. The client will not need to be catheterized. It is a one-time specimen, so urine will not be collected for 24 hours.

15

Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?
a)Incontinence after the age of 3 years is not normal.
b)Daytime continence is usually not achieved by boys until age 5.
c)Boys may walk by 1 year and should be continent by 3 years.
d)Boys may take longer for daytime continence than girls.

Boys may take longer for daytime continence than girls.

Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age

16

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

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.

17

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 first voiding of the day
c)the bedtime voiding
d)the sample collected immediately after lunch

the first voiding of the day

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.

18

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?
a)Intermittent specimen
b)Clean-catch specimen
c)24-hour specimen
d)Random 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.

19

Which catheter would the nurse use to drain a client’s bladder for short periods (5 to 10 minutes)?
a)indwelling urethral catheter
b)suprapubic catheter
c)Foley catheter
d)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.

20

Urinary catheterization is the most common cause of healthcare-associated infection (HAI).
a)True
b)False

True

The catheter is not in the bladder, so urine in the tubing is not sterile.

21

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)a bag attached by adhesive backing to the skin around the genitals
b)a urine drainage tube inserted but not left in place
c)a flexible sheath that is rolled around the penis
d)a urine drainage tube that is left in place over a period of time

a flexible sheath that is rolled around the penis

A condom catheter is a flexible sheath that is rolled around the penis. A urinary bag (U-bag) is a bag attached by adhesive backing to the skin surrounding the genitals. A straight catheter is a urine drainage tube inserted but not left in place. A retention (or indwelling) catheter is a urine drainage tube that is left in place over a period of time

22

What accurately describes a guideline when inserting an indwelling catheter?
a)Use the largest appropriate-sized catheter.
b)Use clean technique when inserting a catheter.
c)Avoid irrigation unless needed to relieve an obstruction.
d)Maintain an open system whenever possible.

Avoid irrigation unless needed to relieve an obstruction.

Irrigation should be avoided unless there is an obstruction to prevent infection. A closed system should be maintained using sterile technique. The smallest appropriate-sized catheter should be used.

23

The nurse is assessing a client’s bladder volume using an ultrasound bladder scanner. Which nursing actions are performed correctly? Select all that apply.
a)The nurse presses and holds the END button until it beeps 3 times and then reads the volume measurement on the screen.
b)The nurse places the scanner head on the gel or gel pad, with the directional icon on the scanner head pointed away from the client’s head.
c)The nurse places a generous amount of ultrasound gel or gel pad midline on the client’s abdomen, about 1 to 1.5 inches above the symphysis pubis.
d)The nurse adjusts the scanner head to center the bladder image on the crossbars.
e)The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx).
f)The nurse gently palpates the client’s symphysis pubis.

• The nurse gently palpates the client’s symphysis pubis.
• The nurse places a generous amount of ultrasound gel or gel pad midline on the client’s abdomen, about 1 to 1.5 inches above the symphysis pubis.
• The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx).
• The nurse adjusts the scanner head to center the bladder image on the crossbars.
To correctly use the ultrasound bladder scanner, the nurse would gently palpate the client’s symphysis pubis. Palpation identifies the proper location and allows for correct placement of scanner head over the client’s bladder. The nurse would place a generous amount of ultrasound gel midline on the client’s abdomen. The gel is necessary to conduct the ultrasound waves for an accurate reading. The nurse would aim the scanner head toward the bladder. Failure to point the scanner in this direction will give erroneous results. The nurse would adjust the scanner head to center the bladder image on the crossbars. This step is necessary to record the most accurate results.

24

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?
a)“Stress causes the muscles to become tense.”
b)“You require greater privacy to void.”
c)“You might have a neurologic condition.”
d)“What medications are you taking?”

“Stress causes the muscles to become tense.”

A person's muscles may become so tense that relaxation of the perineal muscles does not occur, and voiding is inhibited.

25

Use of an indwelling urinary catheter leads to the loss of bladder tone.
a)False
b)True

True

26

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)Blood
b)Infection
c)Stasis
d)Dehydration

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

27

What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?

a)The client can apply it himself with minimal supervision.
b)It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.
c)A sterile urine specimen can be obtained from the drainage bag tubing.
d)It can be left in place for a long period of time.

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The catheter is not in the bladder, so urine in the tubing is not sterile.

28

The nurse is attempting to insert a urinary catheter into a female client's bladder and realize the catheter has been inserted into the vagina. Which action is most appropriate?
a)Immediately remove the catheter from the vagina, contact the primary care provider and anticipate an order for prophylactic antibiotics.
b)Ask the client to bear down until the catheter is expelled.
c)Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.
d)Remove the catheter from the vagina and attempt to insert it into the bladder.

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter.

Start the procedure over and attempt to place the new catheter directly above misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Never remove a catheter from the vagina and insert it in the urethra as this action can cause cross-contamination

29

The nurse is observing the unlicensed assistive personnel (UAP) assist the client with the bedpan. The nurse would intervene if which action, by the UAP, is noted?
a)UAP positions the bedpan so the client’s buttocks rest on the shallow end of the regular bedpan.
b)UAP places the hand closest to the client palm up, under the lower back, and assists with lifting.
c)UAP applies powder to the rim of the bedpan.
d)UAP places a waterproof pad under the client’s buttocks before placing bedpan.

UAP positions the bedpan so the client’s buttocks rest on the shallow end of the regular bedpan.

It is important to place the bedpan in the proper position to prevent spills onto the bed, ensure client comfort, and prevent injury to the skin from a misplaced bedpan. Therefore, the UAP should position the bedpan so the client’s buttocks rest on the rounded shelf of the regular bedpan. Applying powder to the rim of the bedpan helps keep the bedpan from sticking to the client's skin and makes it easier to remove, unless it is contraindicated. The nurse uses less energy when placing the hand closest to the client palm up, under the lower back, and assisting with client lifting. A waterproof pad protects the bed from bedpan spillage.

30

To promote drainage of a client’s Foley catheter, which intervention would be most important for the nurse to implement?
a)Confirming the catheter tubing is not lying under the client
b)Keeping the catheter drainage bag off the floor at all times
c)Ensuring the balloon on the catheter is properly inflated with insertion
d)Securing the catheter to the client’s thigh or abdomen after placement

Confirming the catheter tubing is not lying under the client

The measure that directly relates to proper drainage of the catheter is being sure that the catheter tubing is free and clear of any obstructions, such as being under the client. The drainage bag should also be lower than the client’s bladder. The drainage bag should not be on the floor to prevent infection. The nurse would secure the catheter after insertion to prevent pulling of the catheter, which can cause irritation. The nurse would also ensure the balloon on the catheter is properly inflated to prevent movement of the catheter, which can also cause irritation

31

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 of the following would the nurse document as an abnormal finding?
a)Moist perineal skin
b)Reddened perineal skin
c)Presence of smegma
d)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.

32

The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the mostlikely cause of the resistance?
a)The diameter of the catheter is too large.
b)The nurse failed to deflate the retention balloon after pretesting it for integrity.
c)The client has an occult abscess in the urethra.
d)The client has an enlarged prostate.

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.

33

A nurse is working primarily with adult and older adult clients. Which lifespan considerations should the nurse keep in the mind when working with these populations? Select all that apply.
a)Older adults may try to manage incontinence by restricting intake of fluids.
b)Men have a higher risk of developing urinary incontinence than women.
c)Because of decreased arterial perfusion, kidney function progressively decreases later in life.
d)Symptoms of a urinary tract infection in an older adult include painful urination and a high fever.
e)Older men may experience urinary hesitancy and difficulty starting the urinary stream.
f)Urinary incontinence is a normal part of aging.

• Older men may experience urinary hesitancy and difficulty starting the urinary stream.
• Older adults may try to manage incontinence by restricting intake of fluids.
• Because of decreased arterial perfusion, kidney function progressively decreases later in life.
Older men experience urinary hesitancy and delayed urinary stream related to prostatic hypertrophy. Older adults may attempt to manage incontinence by restricting fluid intake, using absorbent pads in clothing, and changing clothing. Kidney function decreases with age due to cardiovascular changes. Urinary incontinence is not usually a health problem in the early to middle adult years. Women have a higher risk of developing urinary incontinence due to lower estrogen levels and weakened perineal muscles.

34

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

While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

35

Which is the test that would provide an accurate measurement of the kidney's excretion of creatinine?

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.

36

The nurse is choosing a collection device to collect urine from a nonambulatory male client? What would be the nurse’s best choice?
a)Urinal
b)Large urine collection bag
c)Specimen hat
d)Bedpan

Urinal

A urinal is the best choice to collect urine from a nonambulatory male client. A specimen hat is for a commode. A bedpan is not the best choice for a male client. A large urine collection bag would be used with an indwelling catheter

37

The nurse is reviewing the chart of an elderly client who exhibits signs of confusion. Which laboratory value would indicate to the nurse that intervention is needed?
a)Hemoglobin - 40%
b)Magnesium - 2.5 mEq/L
c)Urine culture & sensitivity - 100,000/mL
d)Blood urea nitrogen (BUN) - 7 mg

Urine culture & sensitivity - 100,000/mL

100,000 organisms per milliliter in an urine culture and sensitivity specimen is positive of a urinary tract infection. BUN, hemoglobin, and magnesium are all within the normal ranges.

38

The nurse is caring for a client with urinary incontinence who has a prescription for a postvoid residual (PVR) collection. 45 mL of amber urine is returned via PVR. Which appropriate action would the nurse take with this data collection?
a)Perform a bladder scan.
b)Encourage the client to drink more fluids.
c)Wait 30 minutes and re-catheterize the client.
d)Document the finding.

Document the finding.

A PVR of less than 50 mL indicates the bladder is adequately emptying, so the nurse should document the findings. Since this normal there is no need to encourage more fluids, re-catheterize the client, or perform a bladder scan.

39

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:
a)Deflate the balloon, withdraw the catheter, and use a smaller sized catheter.
b)Stop, deflate the balloon, withdraw the catheter 2 to 4 cm, and slowly reinflate.
c)wait for 30 seconds, help the client to relax, and attempt inflation again.
d)deflate the balloon, insert the catheter further, and slowly attempt reinflation.

deflate the balloon, insert the catheter further, and slowly attempt reinflation.

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 inch (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.

40

The nurse mentor is observing a novice nurse prepare to insert an indwelling catheter for a female client with urinary retention. The mentor would intervene, if which action by the novice nurse is noted?
a)The novice selected an 18 French Foley catheter to insert.
b)The novice assisted the client to a dorsal recumbent position with knees flexed, feet about 2 feet apart.
c)The novice asked the client to take a deep breath when resistance was met during insertion of the catheter.
d)The novice placed a trash receptacle within easy reach.

The novice selected an 18 French Foley catheter to insert.

A 14F to 16F size catheter should be used when catheterizing an adult client. Size 18F can distend the urethra and cause more discomfort to the client during the procedure, as well as increase erosion of the bladder. If resistance is met, having the client take a deep breath helps relaxes the external sphincter. Placing a trash receptacle within easy reach trash allows for prompt disposal of used supplies and reduces the risk of contaminating the sterile field. The dorsal recumbent position allows adequate visualization of the urinary meatus.

41

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)Reflex incontinence
b)Stress incontinence
c)Functional incontinence
d)Transient incontinence

Functional incontinence

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.

42

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)casts.
b)calculi.
c)pus.
d)protein.

pus.

Pyuria is the presence of pus in the urine. Pyuria occurs in the presence of any UTI.

43

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 catheter is not in the bladder, so urine in the tubing is not sterile

44

A nurse in a provider's office is evaluating a client who reports losing control of urine whenever she coughs, laughs, or sneezes. The client relates a hx of 3 vaginal births, but no serious accidents, or illnesses. Which of the following interventions should the nurse suggest for helping to control or eliminate the client's incontinence? (SATA)

  1. Limit total daily fluid intake
  2. Decrease or avoid caffeine
  3. Take calcium supplements
  4. Avoid drinking alcohol
  5. Use the Crede maneuver

B. Caffeine is a bladder irritant and can worsen stress incontinence

D. Alcohol is a bladder irritant and can worsen stress incontinene

45

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

  1. Check to see whether the catheter is patent
  2. Reassure the client that it is not possible for her to urinate
  3. Recatheterize the bladder with a larger gauge catheter
  4. Collect urine specimen for urinalysis

A. A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate.

46

A nurse is caring for a client who has a prescription for a 24-hour urine collection. Which of the following actions should the nurse take?

  1. Discard the first voiding
  2. Keep the urine in a single container at room temp.
  3. Ask the client to urinate and pour the urine into a specimen container
  4. Ask the client to urinate into the toilet, stop midstream, and finish urinating into the specimen container

A. The nurse should discard the first voiding of the 24-hour urine specimen, and note the time.

47

A nurse is reviewing factors that increase the risk of urinary tract infections (UTI's) with a client who has recurrent UTI's. Which of the following factors should the nurse include? SATA

  1. Frequent sexual intercourse
  2. Lowering of testosterone levels
  3. Wiping from front to back
  4. location of the urethra in relation to the anus
  5. Frequent catheterization

A. Having frequent sexual intercourse increases the risk of UTI's in both men and women.

D. The close proximity of the female urethra to the anus is a factor that increases the risk of UTI's

E. Frequent catheterization and the use of indwelling catheters are risk factors for UTI's.

48

A nurse is preparing to initiate a bladder retraining program for a client who has incontinence. Which of the following actions should the nurse take? SATA

  1. Establish a schedule of urinating prior to meal times
  2. Have the client record urination times
  3. Gradually increase the urination intervals
  4. Remind client to hold urine until the next scheduled urination time
  5. Provide a sterile container for urine

B. The nurse should ask the client to keep track of urination times a record of progress toward the goal of 4-hr intervals between urination

C. Gradually increasing the urination intervals helps the client progress toward the goal of 4-hr intervals between urination

D. The nurse should remind the client to hold urine until the next scheduled urination time as part of progressing toward the goal of 4-hr intervals between urination

49

Which scenario does not illustrate a normal lifespan variant regarding urination?
a)The urine of a neonate, 5 hours old, appears pink-tinged.
b)An 8-year-old is continent during the day but is incontinent 2 times during the night.
c)A toddler age 3 1/2 is showing interest in being ready for toilet training by showing that he can undress himself and by being able to stay dry for 2 hours at a time.
d)A 10-year-old child has been voiding straw-colored urine 6 or 7 times a day.

An 8-year-old is continent during the day but is incontinent 2 times during the night.

By the age of 5, children should be continent both during the day and the night. Although most children in North America achieve daytime continence by 3 years of age, some can take a bit longer. Most children will achieve daytime urinary control by 3 to 4 years of age. The first voiding may be slightly pink-tinged. This is caused by uric acid crystals being excreted. School-age children should achieve urinary elimination habits that are similar to adults. This frequency and color are very normal.

50

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?
a)Foley catheter
b)indwelling urethral catheter
c)intermittent urethral catheter
d)retention catheter

intermittent urethral catheter

An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted

51

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)Wash the penis with antimicrobial soap and dry thoroughly.
b)Keep the tip of the tubing 2-3 inches (5 to 7.5 cm) beyond the tip of the penis.
c)Remove the catheter every 8 hours, or more often in humid weather.
d)Fasten the condom securely enough to prevent leakage without constricting the blood vessels.

Fasten the condom securely enough to prevent leakage without constricting the blood vessels.

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.

52

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.

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


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