Question 1

Which assessment finding needs to be communicated promptly to the patient's health care provider?

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?

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?

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The nurse is discontinuing the patient's indwelling urinary catheter.The catheter is not easily withdrawn after the balloon is deflated.Which is the appropriate nursing action?

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?

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?

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?

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?

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?

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?

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?

Accepted Answer

The nurse can act as a patient advocate by suggesting noninvasive alternatives to catheterization use.Bladder training programs can be used to promote continence for children and adults.Catheterization should be avoided whenever possible due to the risk of urinary infection.Disposable undergarments should be used as a last resort if bladder training is unsuccessful.

Question 12

Which assessment finding leads the nurse to question an order for an abdominal flat plate test?

Accepted Answer

The abdominal flat plate test is an x-ray diagnostic test so the nurse should question the order for a pregnant patient.Claustrophobia,renal failure,and shrimp allergy are not contraindications for the test.

Question 13

Which teaching will the nurse provide to the patient before having an intravenous pyelogram (IVP)?

Accepted Answer

Contrast dye used for the IVP can be harmful to the kidneys so the patient should drink lots of water afterward to increase urine output.The bladder should not be full for the IVP test and an endoscope is not used.No urine discoloration is expected after IVP testing.

Question 14

Which is the appropriate method to obtain a urinalysis specimen for culture and sensitivity from an incontinent female patient?

Accepted Answer

The nurse should perform straight catheterization to obtain a clean catch urinalysis from an incontinent female patient.The patient will not be able to provide a midstream or double-voided specimen.Leaving the bedpan under the patient will lead to skin breakdown and contamination of the specimen.

Question 15

Which assessment finding supports the nursing diagnosis overflow urinary incontinence related to urethral obstruction?

Accepted Answer

Overflow urinary incontinence occurs when small amounts of urine are lost due to retention of large amount of urine in the bladder.A postvoid residual of 900 mL after incontinence of small amounts of urine supports the overflow urinary incontinence diagnosis.Overflow urinary incontinence does not apply to patients with urostomy appliances.Incontinence of urine with coughing or sneezing demonstrates stress incontinence.Inability to indicate need to urine leads to functional incontinence.

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?

Accepted Answer

Indwelling urinary catheters should be changed every 4 to 6 weeks.The nurse should contact the health care provider for an order to change the catheter after it has been in place for 8 weeks.Removal of the catheter is not an option for the patient with a spinal cord injury as the damage to the nerves is permanent.Irrigation and urinalysis are not needed.

Question 17

The patient's urinalysis indicates increased specific gravity of the urine.Which finding does the nurse anticipate will be found upon assessment?

Accepted Answer

Increased specific gravity occurs when the urine is concentrated.This can occur with dehydration,SIADH,or fluid restrictions.The patient's thirst and dry oral mucus membranes are consistent with increased specific gravity.History of BPH,resolved UTI,and COPD do not correlate with increased specific gravity of the urine.

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?

Accepted Answer

Sleep deprivation is appropriate for the patient due to frequent need to use the toilet at night.The elderly patient is at risk for falls when ambulating to the toilet.Urinary frequency is appropriate as the patient has a constant urge to void.Risk for urge urinary incontinence is also appropriate as urinary tract inflammation can lead to loss of urine.Risk for infection is not appropriate as the patient already has a bladder infection.

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?

Accepted Answer

The appropriate action of the nurse is to scan the patient's bladder to determine how much urine is present.The nurse may need to catheterize the patient if a very large amount of urine is in the bladder or encourage fluids if there is minimal urine present.Assessment of the perineum will not assist the patient to void.The nurse will not be able to send a urine sample until the patient voids or is catheterized.Absorbent undergarments are not needed if the patient is unable to void.

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?

Accepted Answer

The safest option for this patient is to apply a condom catheter to facilitate containment of urine.Indwelling,suprapubic,and straight catheters will increase risk of urinary tract infection.

Quiz 36: Urinary Elimination