Chapter 45 Urinary Elimination Answers 1

t Chapter 45: Urinary Elimination MULTIPLE CHOICE 1. The nurse determines that the nursing diagnosis stress urinary incontinence related to decreased pelvic muscle tone is the most appropriate for an oriented adult female client. A therapeutic nursing intervention based on this diagnosis is to: 1. Apply adult diapers 2. Catheterize the client 3. Administer Urecholine 4. Teach Kegel exercises ANS: 4 Pelvic floor exercises, also known as Kegel exercises, improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups. These exercises have demonstrated effectiveness in treating stress incontinence, overactive bladders, and mixed causes of urinary continence. The client is oriented and therefore could be taught Kegel exercises to improve pelvic floor muscle tone. Applying adult diapers does not improve the client’s problem of incontinence and places the client at risk for skin breakdown. Because bladder catheterization carries the risk for urinary tract infection (UTI), it is preferable to rely on other measures for management of incontinence. The nurse can support the use of Kegel exercises as an inexpensive nonpharmacological intervention to reduce the client’s stress incontinence. Bethanechol (Urecholine) stimulates the parasympathetic nervous system to promote complete bladder emptying and is primarily used to treat urinary retention and possible overflow incontinence. Nonpharmacological approaches should be attempted before pharmacological approaches are taken. DIF: A REF: 1148 OBJ: Comprehension TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 2. Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter? 1. Empty the drainage bag at least every 8 hours. 2. Clean up the length of the catheter to the perineum. 3. Use clean technique to obtain a specimen for culture and sensitivity. 4. Place the drainage bag on the client’s lap while transporting the client to testing. ANS: 1 Test Bank 45-2 The urinary drainage bag should be emptied at least every 8 hours. If large outputs are noted, more frequent emptying will be required. The perineum should be cleansed and then down the catheter for a length of approximately 10 cm (4 inches). Only use sterile technique to collect specimens from a closed drainage system. Avoid raising the drainage bag above the level of the bladder. If it becomes necessary to raise the bag during transfer of the client to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first. The drainage bag can be attached to the wheelchair below the level of the client’s bladder for transport. It should not be placed on the client’s lap. DIF: A REF: 1164 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 3. The nurse suspects that the client has a bladder infection based on the client's exhibiting an early sign or symptom such as: 1. Chills 2. Hematuria 3. Flank pain 4. Incontinence ANS: 2 Irritation to the bladder and urethral mucosa results in blood-tinged urine (hematuria). Hematuria is a sign of a bladder infection. Chills are a more systemic symptom associated with pyelonephritis. Flank pain is a more systemic symptom associated with pyelonephritis. Incontinence is not a symptom of a bladder infection. DIF: A REF: 1134 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 4. When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should: 1. Disconnect the catheter from the drainage tubing 2. Withdraw urine from a urinometer 3. Open the drainage bag and removing urine 4. Use a needle to withdraw urine from the catheter port ANS: 4 Test Bank 45-3 A sterile specimen can be obtained through the special port found on the side of the indwelling catheter. The nurse clamps the tubing below the port, allowing fresh, uncontaminated urine to collect in the tube. After the nurse wipes the port with an antimicrobial swab, a sterile syringe needle is inserted, and at least 3 to 5 mL of urine is withdrawn. Using sterile technique, the nurse transfers the urine to a sterile container. The catheter should not be disconnected from the drainage tubing. The system should remain a closed system to prevent infection. A urinometer is a device used to determine the specific gravity of urine. It is not a sterile device and should not be used for obtaining a sterile urine specimen. Urine should not be obtained from a drainage bag for a specimen, because the urine would not be fresh and would be contaminated from microorganisms in the drainage bag. DIF: A REF: 1140 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 5. Immediately after an intravenous pyelogram (IVP) the nurse should observe the client for which of the following? 1. Infection in the urinary bladder 2. An allergic reaction to the contrast material 3. Urinary suppression caused by injury to kidney tissues 4. Incontinence as a result of paralysis of the urinary sphincter ANS: 2 After an IVP the nurse should encourage fluid intake to dilute and flush dye from the client and observe the client for late symptoms of allergy (e.g., rash). There is no increased risk for infection of the urinary bladder from an IVP. This would be more likely with an invasive procedure, such as an endoscopy (cystoscopy). An IVP should not injure tissues of the kidney or cause paralysis of the urinary sphincter. DIF: A REF: 1145 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 6. A client with an excessive alcohol intake has a reduced amount of antidiuretic hormone (ADH). The nurse anticipates the client will exhibit: 1. Hematuria 2. An increased blood pressure 3. Dry mucous membranes 4. A low serum sodium level ANS: 3 Test Bank 45-4 Alcohol inhibits the release of ADH, resulting in increased water loss in urine. The client may show signs of decreased fluid volume (dehydration), including dry mucous membranes. The effects of excessive alcohol intake and reduced antidiuretic hormone will not cause hematuria. Having decreased levels of antidiuretic hormone will lead to increased urine production. The client may exhibit a decreased blood pressure resulting from decreased fluid volume and an increased serum sodium level with dehydration. DIF: A REF: 1133 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 7. A client is going to have a cystoscopy. Which of the following reflects the correct information that should be taught before the procedure? 1. “Are you allergic to iodine?” 2. “There will be no need to have a special consent form.” 3. “You will need to have fluids restricted the evening before the cystoscopy.” 4. “You will probably be given sedatives before the procedure.” ANS: 4 Although this procedure may be accomplished using local anesthesia, it is more commonly performed using general anesthesia or conscious sedation to avoid unnecessary anxiety and trauma for the client. A cystoscopy involves direct visualization. No contrast dye is used; therefore the nurse does not need to ask if the client is allergic to iodine. A signed consent form is obtained. Fluids are not restricted before or after the procedure. The flushing action helps remove bacteria from the urethra. DIF: A REF: 1146 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 8. A postpartum client has been unable to void since her delivery of her baby this morning. Which of the following nursing measures would be beneficial for the client initially? 1. Increase fluid intake to 3500 mL. 2. Insert indwelling Foley catheter. 3. Rinse the perineum with warm water. 4. Apply firm pressure over the bladder. ANS: 3 Test Bank 45-5 The nurse can pour warm water over the client’s perineum and create the sensation to urinate. A client with normal renal function who does not have heart or kidney disease should drink 2000 to 2500 mL of fluid daily. Increasing the client’s fluid intake to 3500 mL is excessive. Because bladder catheterization carries the risk for UTI, it should be avoided if possible. The nurse should try other noninvasive measures to promote urination before calling the health care provider for an order to insert a Foley catheter. The nurse should not apply firm pressure over the bladder of a postpartum woman with an intact nervous system. The nurse could create more damage by exerting force on the client’s uterus at this time. DIF: C REF: 1149 OBJ: Analysis TOP: Nursing Process: Planning MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 9. The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit: 1. Severe flank pain and hematuria 2. Pain and burning on urination 3. A loss of the urge to void 4. A feeling of pressure and voiding of small amounts ANS: 4 With urinary retention, urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the symphysis pubis, restlessness, and diaphoresis. The sphincter temporarily opens to allow a small volume of urine (25 to 60 mL) to escape, with no real relief of discomfort. Severe flank pain and hematuria are supporting data for an upper urinary tract infection (pyelonephritis). Pain and burning on urination are symptoms of a lower urinary tract infection (such as a bladder infection). Supportive data for reflex incontinence would include a loss of the urge to void. DIF: A REF: 1146 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 10. The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? 1. Apply sterile gloves for the procedure. 2. Restrict fluids before the specimen collection. 3. Place the specimen in a clean urinalysis container. 4. Collect the specimen after the initial stream of urine has passed. ANS: 4 Test Bank 45-6 To collect a clean-voided specimen, the nurse should collect the specimen (30 to 60 mL) after the initial stream of urine has passed. Nonsterile gloves are adequate. Fluids are encouraged so the client will be more likely to be able to void. The specimen should be collected in a sterile container and then placed into a plastic specimen bag. DIF: A REF: 1142 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 11. The nurse is aware that clients with chronic alterations in kidney function suffer from insufficient amounts of: 1. Vitamin A 2. Vitamin D 3. Vitamin E 4. Vitamin K ANS: 2 The kidneys play a role in calcium and phosphate regulation by producing a substance that converts vitamin D into its active form. Clients with chronic alterations in kidney function do not make sufficient amounts of the active vitamin D. Clients with chronic alterations in kidney function do not suffer from an insufficient amount of vitamin A, vitamin E, or vitamin K. DIF: A REF: 1131 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 12. In an assessment of a client with reflex incontinence the nurse expects to find that the client has: 1. A constant dribbling of urine 2. An uncontrollable loss of urine when coughing or sneezing 3. No urge to void and an unawareness of bladder filling 4. An immediate urge to void but not enough time to reach the bathroom ANS: 3 The nurse expects to find the client with reflex incontinence to have no urge to void and an unawareness of bladder filling. A constant dribbling of urine may be seen with overflow incontinence. With stress incontinence the client is unable to control loss of urine when coughing or sneezing. Functional incontinence is seen when there is an immediate urge to void but not enough time to get to the bathroom. DIF: A REF: 1152 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination Test Bank 45-7 13. When calculating the daily intake and output, the nurse anticipates that the urinary output for an average adult should be: 1. 800 to 1000 mL/day 2. 1000 to 1200 mL/day 3. 1500 to 1600 mL/day 4. 2000 to 2300 mL/day ANS: 3 Although output does depend on intake, the normal adult urine output is 1500 to 1600 mL/day. DIF: A REF: 1130 OBJ: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 14. A timed urine specimen collection is ordered. The test will need to be restarted if which of the following occurs? 1. The client voids in the toilet. 2. The urine specimen is kept cold . 3. The first voided urine is discarded. 4. The preservative is placed in the collection container. ANS: 1 Missed specimens make the whole collection inaccurate, causing the test to need to be restarted. The urine specimen is kept in a collection container, which may contain preservatives, or the urine may be kept in a collection container on ice. The timed period begins after the client urinates. The first voided urine is discarded, and then the time for collection begins. DIF: A REF: 1140 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 15. The nurse is working with a client who has a urinary diversion. Included in the plan of care for this client is instruction that: 1. Special clothing will need to be ordered in order to fit around the diversion 2. A stomal bag will only need to be worn at night 3. A reduction in physical activity will be planned 4. Special skin care is a priority ANS: 4 Test Bank 45-8 Special skin care is a priority in caring for a client with a urinary diversion. Local irritation and skin breakdown occur when urine comes in contact with the skin for long period. Special clothing is not necessary for the client with a urinary diversion, but the client must wear a stomal pouch continuously because there is no sphincter control for regulation of urine flow. There is no need to plan for a reduction in activity. DIF: A REF: 1134 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 16. Which of the following would indicate that the clinician performing the catheterization of a female client was competent? 1. Keeping both hands sterile throughout the procedure 2. Reinserting the catheter if it was misplaced initially in the vagina 3. Inflating the balloon to test it before catheter insertion 4. Advancing the catheter 7 to 8 inches ANS: 3 Before inserting the indwelling catheter, the balloon should be tested by injecting the fluid from the prefilled syringe into the balloon port. The dominant hand is kept sterile throughout the procedure. The nondominant hand is not kept sterile because it touches the client. If the catheter is misplaced, it should be left in the vagina as a landmark indicating where not to insert, and another sterile catheter should be inserted into the urethra. The catheter should be advanced 2 to 3 inches in the female client. DIF: A REF: 1159 OBJ: Comprehension TOP: Nursing Process: Evaluation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination 17. The nurse caring for a client who is receiving closed catheter irrigation instills 950 mL of normal saline irrigant during the shift. There is a total of 1725 mL in the drainage bag. The nurse calculates the client’s urinary output for the shift to be: 1. 775 mL 2. 950 mL 3. 1725 mL 4. 2675 mL ANS: 1 The amount of fluid used to irrigate the bladder and catheter should be subtracted from the total output to determine an accurate urinary output. 1725 mL 950 mL = 775 mL. DIF: A REF: 1168 OBJ: Comprehension TOP: Nursing Process: Implementation MSC: NCLEX® test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination