Question 1

Which assessment finding needs to be communicated promptly to the patient's health care provider?&#10;A) Postvoid residual of 15 mL of urine.&#10;B) Leakage of small amounts of urine when coughing.&#10;C) Urine output of 160 mL over the last 8 hours.&#10;D) Patient's report of an urge to void during palpation of the bladder.

Accepted Answer

Urinary output should be at least 30 mL/hour so urine output of 160 mL for 8 hours should be reported promptly to the health care provider.A postvoid residual of 15 mL is not a problem.Stress incontinence does not need to be promptly communicated to the health care provider.It is normal for patients to feel an urge to void during palpation of the bladder.

Question 2

The patient reports feeling an urge to urinate even though an indwelling urinary catheter is in place.Which is the priority action of the nurse?&#10;A) Measure the patient's urinary output.&#10;B) Ensure that the catheter tubing is not kinked.&#10;C) Provide perineal care to the patient for comfort.&#10;D) Reassure the patient that the sensation is to be expected.

Accepted Answer

The patient will feel an urge to urinate if the catheter tubing becomes kinked and the urine is not able to drain.The nurse should first check to make sure that the tubing is patent and draining freely.Once this is done the nurse can measure urinary output and provide perineal care.If there is no evidence of urethral irritation or kinked tubing,the patient may be reassured that the sensation may be expected.

Question 3

The patient's urinalysis indicates small amounts of protein in the urine.Which diagnosis does the nurse anticipate to see in the patient's electronic health record?&#10;A) Diabetes mellitus&#10;B) Diabetes insipidus&#10;C) Hypothyroid disease&#10;D) Hyperparathyroid disease

Accepted Answer

Diabetes mellitus can cause damage to the glomerular membrane allowing protein to seep into the urine.Diabetes insipidus,hypothyroid disease,and hyperparathyroid disease do not cause proteinuria.

Question 4

The nurse is discontinuing the patient's indwelling urinary catheter.The catheter is not easily withdrawn after the balloon is deflated.Which is the appropriate nursing action?&#10;A) Reattach the syringe and attempt to withdraw more water from the balloon.&#10;B) Ask the patient to bear down as the catheter is withdrawn with gentle pressure.&#10;C) Review the patient's chart to see how much water was inserted into the balloon.&#10;D) Explain to the patient that removal of the catheter may cause significant discomfort.

Accepted Answer

The syringe should be reattached to withdraw any remaining water from the balloon.The nurse should not ask the patient to bear down; catheter removal should be painless.The nurse should check the balloon for more water rather than checking the chart to see how much water was instilled.

Question 5

The nurse is performing urinary catheterization for a female patient.The catheter will not advance any further but there is no urine output.What is the appropriate action of the nurse?&#10;A) Withdraw the catheter and notify the health care provider immediately.&#10;B) Palpate the patient's bladder to assess for fullness,tenderness,or distention.&#10;C) Leave the catheter in place and reattempt insertion with a new sterile catheter.&#10;D) Utilize the bladder scanner to determine how much urine is in the patient's bladder.

Accepted Answer

The catheter has been inadvertently inserted into the patient's vagina.The nurse should leave the catheter in place and reattempt insertion with a new sterile catheter.There is no need to notify the health care provider immediately.Palpation of the bladder and bladder scanning should be completed prior to insertion of the catheter.

Question 6

A patient with a Foley catheter needs a urine sample for culture and sensitivity.What is the appropriate action for the nurse to take?&#10;A) Disconnect the drainage tube from the catheter.&#10;B) Withdraw urine from the closed system drainage bag.&#10;C) Empty contents of the drainage bag into the specimen cup.&#10;D) Attach a sterile syringe to the catheter port to withdraw urine.

Accepted Answer

The nurse should attach a sterile syringe to the catheter port to withdraw urine.Separating the drainage tube from the catheter breaches sterile technique and can cause introduction of bacteria into the system.Because urine in the drainage bag can rapidly grow bacteria,never take a urine sample from the drainage bag.

Question 7

Which outcome is appropriate for the patient with risk for urinary tract infection related to recent urinary catheterization?&#10;A) The patient's urine will remain free from white blood cells and bacteria.&#10;B) The patient will take prescribed antibiotics until the urinary symptoms are gone.&#10;C) The patient will have serial urine cultures to ensure that the infection is resolved.&#10;D) The patient will carefully wipe the perineal area from front to back after voiding.

Accepted Answer

An appropriate outcome for the risk for urinary tract infection diagnosis is that the patient's urine will remain free from white blood cells and bacteria.Antibiotics should not be prescribed unless an infection is present,which negates the risk for infection diagnosis.Serial urine cultures will take place if an infection is present.Careful perineal care is an intervention,not an outcome.

Question 8

Which assessment finding explains the cause of the patient's stress urinary incontinence?&#10;A) The patient uses a wheelchair and cannot get to the toilet in time to void.&#10;B) The patient gave birth to six babies who weighed more than 9 pounds.&#10;C) The patient suffered a spinal cord injury and has no sensation below the waist.&#10;D) The patient self-catheterizes due to urinary retention from multiple sclerosis.

Accepted Answer

Giving birth to six large babies causes weakness of pelvic organs and subsequent stress incontinence.Inability to reach the toilet in time to void indicates a functional incontinence.Self-catheterization and spinal cord injury do not lead to stress incontinence.

Question 9

The patient knocked over the specimen container and spilled some of the urine that had been collected for a 24-hour urine analysis.Which is the appropriate action of the nurse?&#10;A) Start the collection over again with a new container.&#10;B) Inform the patient that the test will have to be canceled&#10;C) Replace the lid on the container and continue the collection.&#10;D) Extend the collection period by 2 hours for a replacement void.

Accepted Answer

The nurse should start the collection over again with a new container as the specimen collection will not be accurate.The test does not need to be canceled.The nurse cannot extend the collection period as that will lead the test to be inaccurate.

Question 10

The nurse is inserting an indwelling urinary catheter before the patient has abdominal surgery.Which type of catheter will the nurse utilize for the procedure?&#10;A) Straight catheter&#10;B) Single-lumen catheter&#10;C) Double-lumen catheter&#10;D) Triple-lumen catheter

Accepted Answer

The nurse will use a double-lumen catheter for the patient.One lumen will inflate the balloon and the other will drain the urine from the bladder.Straight or single-lumen catheters are used for intermittent catheterization.Triple-lumen catheters are used for continuous bladder irrigation.

Question 11

The family requests insertion of a Foley catheter to address the elderly patient's frequent episodes of incontinence.Which is the best action of the nurse?&#10;A) Obtain an order for an indwelling urinary catheter.&#10;B) Teach family to perform intermittent straight catheterization.&#10;C) Utilize disposable absorbent undergarments for the patient.&#10;D) Implement a bladder training program to promote continence.

Accepted Answer

The answer of The family requests insertion of a Foley...

Question 12

Which assessment finding leads the nurse to question an order for an abdominal flat plate test?&#10;A) The patient is very claustrophobic.&#10;B) The patient is 8 weeks pregnant.&#10;C) The patient has a history of renal failure.&#10;D) The patient is allergic to iodine and shrimp.

Accepted Answer

The answer of Which assessment finding leads the nurse to...

Question 13

Which teaching will the nurse provide to the patient before having an intravenous pyelogram (IVP)?&#10;A) Drink water and do not void so the bladder will be full during the test.&#10;B) An urge to void may be felt as the endoscope passes through the urethra.&#10;C) The urine may have an orange or pink for a day or two following the test.&#10;D) Drink plenty of water afterward to prevent kidney damage from the contrast dye.

Accepted Answer

The answer of Which teaching will the nurse provide to...

Question 14

Which is the appropriate method to obtain a urinalysis specimen for culture and sensitivity from an incontinent female patient?&#10;A) Obtain a midstream specimen.&#10;B) Perform straight catheterization.&#10;C) Obtain a double-voided specimen.&#10;D) Leave a fresh bedpan under the patient.

Accepted Answer

The answer of Which is the appropriate method to obtain...

Question 15

Which assessment finding supports the nursing diagnosis overflow urinary incontinence related to urethral obstruction?&#10;A) Advanced dementia prevents the patient from indicating need to urinate&#10;B) Postvoid residual of 900 mL after incontinence of small amounts of urine&#10;C) Leakage of urine around the urostomy appliance leading to skin irritation&#10;D) Incontinence of large amounts of urine every time the patient coughs or sneezes

Accepted Answer

The answer of Which assessment finding supports the nursing diagnosis...

Question 16

The home care nurse is caring for a patient with an indwelling urinary catheter after spinal cord injury.The catheter is patent with clear yellow urine after being in place for 8 weeks.Which is the appropriate action of the nurse?

A) Request an order for a urinalysis with culture and sensitivity.
B) Irrigate the patient's catheter using 60 mL of sterile normal saline.
C) Remove the catheter immediately and notify the health care provider.
D) Contact the health care provider for an order to change the catheter.

Accepted Answer

The answer of The home care nurse is caring for...

Question 17

The patient's urinalysis indicates increased specific gravity of the urine.Which finding does the nurse anticipate will be found upon assessment?&#10;A) The patient uses supplemental oxygen due to COPD.&#10;B) The patient is thirsty with dry oral mucus membranes.&#10;C) The patient has a history of benign prostatic enlargement.&#10;D) The patient just completed antibiotics for a bladder infection.

Accepted Answer

The answer of The patient's urinalysis indicates increased specific gravity...

Question 18

The nurse is caring for an older adult patient who has a constant urge to void due to a bladder infection.Which are the appropriate nursing diagnoses for this patient?&#10;A) Sleep deprivation related to frequent need to use the toilet during the night&#10;B) Risk for falls related to getting up frequently to use the bathroom at night&#10;C) Impaired urinary elimination: frequency related to urinary tract inflammation&#10;D) Risk for infection related to bacterial invasion of urinary tract&#10;E) Risk for urge urinary incontinence related to urinary tract inflammation

Accepted Answer

The answer of The nurse is caring for an older...

Question 19

The nurse is caring for a patient who feels the urge to urinate but is unable to void.Which is the appropriate action of the nurse?&#10;A) Scan the patient's bladder to see how much urine is present.&#10;B) Obtain a urine sample for urinalysis,culture,and sensitivity.&#10;C) Perform a focused physical assessment of the patient's perineum.&#10;D) Help the patient to utilize absorbent undergarments for protection.

Accepted Answer

The answer of The nurse is caring for a patient...

Question 20

The nurse is caring for an incontinent male patient with a large sacral pressure injury.Which is the safest intervention that will maintain skin integrity and facilitate healing of the ulcer?&#10;A) Obtain a surgical consult for placement of a suprapubic urinary catheter.&#10;B) Apply a condom catheter attached to a bedside urinary drainage bag.&#10;C) Insert an indwelling urinary catheter attached to a small volume drainage bag.&#10;D) Perform intermittent straight catheterization of the patient every 4 to 6 hours.

Accepted Answer

The answer of The nurse is caring for an incontinent...

Question 21

Which assessment findings indicate to the nurse that the older adult patient has a urinary tract infection?&#10;A) Confusion and irritability&#10;B) Urinalysis is positive for hyaline casts and ketones.&#10;C) Urinalysis is negative for nitrites and white blood cells.&#10;D) Reports frequency and burning with urination&#10;E) Has had two uncharacteristic episodes of incontinence

Accepted Answer

The answer of Which assessment findings indicate to the nurse...

Deck 36: Urinary Elimination