Question 1

An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plan of care?

Accepted Answer

Urge urinary incontinence is the leakage of urine associated with a strong urge to void. Patients leak urine on the way to or at the toilet and rush or hurry to the toilet. Urinary retention is the inability to empty the bladder. Functional urinary incontinence is incontinence due to causes outside the urinary tract, such as mobility or cognitive impairments. While Impaired skin integrity can occur, it is not the priority at this time, and there is no data to support this diagnosis.

Question 2

A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response?

Accepted Answer

Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Evidence has shown that patients with urgency, stress, and mixed urinary incontinence can eventually achieve continence when treated with pelvic floor muscle training. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail.

Question 3

The patient has a catheter that must be irrigated. The nurse is using a needleless closed irrigation technique. In which order will the nurse perform the steps, starting with the first one?
1) Clean injection port.
2) Inject prescribed solution.
3) Twist needleless syringe into port.
4) Remove clamp and allow to drain.
5) Clamp catheter just below specimen port.
6) Draw up prescribed amount of sterile solution ordered

Accepted Answer

The steps for irrigating with a needleless closed irrigation technique is as follows: Draw up in a syringe the prescribed amount of medication or sterile solution; clamp indwelling retention catheter just below specimen port; using circular motion, clean injection port with antiseptic swab; insert tip of needleless syringe using twisting motion into irrigation port; slowly and evenly inject fluid into catheter and bladder; and withdraw syringe, remove clamp, and allow solution to drain into drainage bag.

Question 4

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?

Accepted Answer

The skill of collecting midstream (clean-voided) urine specimens can be delegated to nursing assistive personnel. The nurse must first determine the timing and frequency of the bladder scan measurement and interprets the measurements obtained. Inserting a straight or an indwelling catheter cannot be delegated. Catheter irrigation or instillation cannot be delegated to nursing assistive personnel.

Question 5

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

Accepted Answer

If no urine appears, the catheter may be in the vagina. If misplaced, leave the catheter in the vagina as a landmark to indicate where not to insert, and insert another sterile catheter. The catheter should be left in place until the new, sterile catheter is inserted. The balloon should not be filled since the catheter is in the vagina. The catheter must be sterile; using alcohol will not make the catheter sterile.

Question 6

A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection?

Accepted Answer

Bacteria in the urine along with other symptoms support a diagnosis of urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal disease. Protein indicates kidney function and damage to the glomerular membrane such as in glomerulonephritis.

Question 7

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is $\bold{most}$ appropriate?

Accepted Answer

To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended; time of last void is most appropriate. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, interference with any activities, and losing urine during coughing or sneezing focus on specific pathological conditions.

Question 8

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, which finding will the nurse expect?

Accepted Answer

Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection.

Question 9

The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report?

Accepted Answer

Cystitis is inflammation of the bladder; associated symptoms include hematuria, foul-smelling cloudy urine, and urgency/frequency. Dysuria is a common symptom of a lower urinary tract infection (bladder). Flank pain, fever, and chills are all signs of pyelonephritis (upper urinary tract).

Question 10

A patient is experiencing oliguria. Which action should the nurse perform first?

Accepted Answer

Oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action.

Question 11

A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?

Accepted Answer

Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. Anxiety can impact bladder emptying due to inadequate relaxation of the pelvic floor muscles and urinary sphincter. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological (does not recognize signals or not drinking enough fluids) or psychological (lonely) condition exists.

Question 12

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine?

Accepted Answer

The flow of urine follows these structures: kidney, ureters, bladder, and urethra.

Question 13

To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?

Accepted Answer

The patient should hold the labia apart to reduce bacterial levels in the specimen. The urethral meatus should be cleansed from the area of least contamination to greatest contamination (or front to back). The initial stream flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 minutes before giving a specimen.

Question 14

A nurse is caring for a male patient with urinary retention. Which action should the nurse take $\bold{first}$?

Accepted Answer

In some patients just helping them to a normal position to void prompts voiding. A urinary catheter would relieve urinary retention, but it is not the first measure; other nursing interventions should be tried before catheterization. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention and is usually not recommended unless the retention is severe. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention.

Question 15

Which assessment question should the nurse ask if stress incontinence is suspected?

Accepted Answer

Stress incontinence can be related to intraabdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of the bladder would rule out retention and overflow. An inability to void completely can refer to urge incontinence. Physiological causes and medications can effect elimination, but this is not related to stress incontinence.

Question 16

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem?

Accepted Answer

Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. To prevent nocturia, suggest that the patient avoid drinking fluids 2 hours before bedtime. Clearing a path to the bathroom, illuminating the path, or shortening the distance to the bathroom may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing stress incontinence.

Question 17

The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria?

Accepted Answer

Dysuria is burning or pain with urination. Hematuria is blood in the urine. Urgency is an immediate and strong desire to void that is not easily deferred. Nocturia is awakening form sleep due to urge to void.

Question 18

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action?

Accepted Answer

Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness, causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow, requiring temporary use of an indwelling urinary catheter. The patient is more likely to retain urine rather than experience uncontrollable voiding.

Question 19

The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect?

Accepted Answer

Some drugs change the color of urine (e.g., phenazopyridine-orange, riboflavin-intense yellow). Eating beets, rhubarb, and blackberries causes red urine. Dark amber urine is the result of high concentrations of bilirubin in patients with liver disease.

Question 20

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?

Accepted Answer

Dehydration, reduced renal blood flow, and increase in antidiuretic hormone secretion elevate specific gravity. Normal specific gravity is 1.0053 to 1.030. An output of 30 mL/hr or less for 2 or more hours would be cause for concern; 80 mL/hr is normal. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease.

Quiz 46: Urinary Elimination

An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plan of care?

A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response?

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection?

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is $\bold{most}$ appropriate?

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, which finding will the nurse expect?

The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report?

A patient is experiencing oliguria. Which action should the nurse perform first?

A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine?

To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?

A nurse is caring for a male patient with urinary retention. Which action should the nurse take $\bold{first}$ ?

Which assessment question should the nurse ask if stress incontinence is suspected?

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem?

The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria?

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action?

The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect?

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?

Quiz 46: Urinary Elimination

An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient's plan of care?

A patient asks about treatment for stress urinary incontinence. Which is the nurse's best response?

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?

A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?

A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection?

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most\bold{most}most appropriate?

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, which finding will the nurse expect?

The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report?

A patient is experiencing oliguria. Which action should the nurse perform first?

A patient requests the nurse's help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient's inability to void?

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine?

To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?

A nurse is caring for a male patient with urinary retention. Which action should the nurse take first\bold{first}first ?

Which assessment question should the nurse ask if stress incontinence is suspected?

A patient has fallen several times in the past week when attempting to get to the bathroom. The patient gets up 3 or 4 times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem?

The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria?

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse's action?

The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect?

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is $\bold{most}$ appropriate?

A nurse is caring for a male patient with urinary retention. Which action should the nurse take $\bold{first}$ ?