Question 1

On the basis of the nurse's assessment of kidney function for an adult patient,which finding is normal?

Accepted Answer

Minimum average hourly output is 30 mL.

Question 2

When observing a patient for symptoms of dehydration,the nurse should observe which assessment?

Accepted Answer

Cardiovascular signs of fluid volume deficit include increased pulse rate,weak pulse,hypotension,decreased pulse volume/pressure,decreased capillary filling,and increased hematocrit.Increased salivation and periorbital edema are signs of fluid volume excess.Diuresis is a renal sign of fluid volume excess.

Question 3

The nurse is caring for a patient who has an indwelling urinary catheter.Which intervention is most important to include in this patient's plan of care?

Accepted Answer

Using a clean washcloth,wipe in a circular motion along the length of the catheter for about 10 cm (4 inches).Allow slack in the catheter so movement does not create tension on it.Empty the drainage bag,and record amounts at least every 3 to 6 hours.The drainage bag must be below the level of the bladder;do not place the bag on the side rails of the bed.

Question 4

In assisting a male patient in using a urinal,which of the following actions should the nurse take? (Select all that apply. )

Accepted Answer

To assist the patient in using a urinal,the nurse should assess the patient's normal urinary elimination habits and look for periods of incontinence.Always determine mobility status before having a patient stand to void,and assess for orthostatic hypotension if the patient has been on prolonged bed rest.If the patient is able to handle the urinal himself,allow him privacy.If the patient is unable to handle the urinal,the nurse will assist by holding it.

Question 5

The nurse is caring for a patient who has an indwelling catheter attached to a drainage bag.To achieve the desired outcome of this procedure,which nursing action should be taken?

Accepted Answer

Check the drainage tubing and the bag to make sure that the tubing does not have dependent loops and the bag is not positioned above the level of the bladder.Check to make sure that the tubing is coiled and is secured to the bed linen,is free of kinks,and is not clamped,and that the patient is not lying on it.

Question 6

The nurse is caring for a patient who is experiencing inadequate bladder emptying.To determine postvoid residual,which technique is most important for the nurse to implement?

Accepted Answer

The bladder scan is most commonly used to measure postvoid residual (PVR);it is the least invasive method of making this determination.

Question 7

When providing care for a patient in need of an indwelling catheter,the nurse understands that which of the following is an indication for this need?

Accepted Answer

Indications for an indwelling catheter include (1)the presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence,and (2)the need for accurate measurement of urinary output in critically ill patients.The incidence of catheter-associated UTI significantly decreases when the nurse gives the prescriber daily reminders to remove unnecessary catheters and suggests the use of alternative noninvasive treatments to manage urinary elimination.

Question 8

When evaluating the health care team member's ability to apply a condom catheter,it is most important for the nurse to provide further instruction for which intervention?

Accepted Answer

Use of an adhesive strip not designed for sheath application may be inflexible and may impede circulation to the penis.Clip hair at the base of the penis.Hair adheres to the condom and is pulled during condom removal or may get caught in rubber as the condom catheter is applied.Apply skin preparation to the penis and allow it to dry.Leave 1 to 2 inches of space between the tip of the glans penis and the end of the condom.

Question 9

The nurse is preparing the patient for a bladder scan to determine postvoid residual (PVR).Which of the following is part of the preparation?

Accepted Answer

The nurse will assist the patient to void,then wait 10 minutes before administering the bladder scan.There is no need to limit either food or fluids before the test.Since the test is completely noninvasive,there is no need to administer an analgesic beforehand.

Question 10

When the balloon on an indwelling urinary catheter is inflated and the patient expresses discomfort,it is essential for the nurse to take which action?

Accepted Answer

If resistance to inflation is noted,or if the patient complains of pain,the balloon may not be entirely within the bladder.Stop inflation,aspirate any fluid injected into the balloon,and advance the catheter a little farther before attempting again to inflate.

Question 11

When providing care for a patient with a suprapubic catheter who has acquired a urinary tract infection (UTI),which intervention is most important for the nurse to implement?

Accepted Answer

Encourage the patient with a UTI to drink at least 2200 mL of fluid per day.The insertion site is cleansed in a circular swabbing pattern so as not to disturb the tubing.Standard care requires the use of clean gloves and securing the catheter to the abdomen.

Question 12

The nurse is planning care for a 12-year-old female patient who needs a Foley catheter inserted.It is most important for the nurse to use a catheter of which size French (Fr)?

Accepted Answer

Gender and age determine catheter size.A 12-Fr catheter may be considered for use in young girls.The prescriber may order a larger size.For infants,5 to 6 Fr is generally used;for children,8 to 10 Fr with a 3-mL balloon is used;and 14 to 16 Fr is indicated for adult women.

Question 13

The nurse has been ordered to perform closed intermittent irrigation of a patient's indwelling urinary catheter.Which intervention is indicative of safe practice?

Accepted Answer

Calculate the fluid used to irrigate the bladder and catheter,and subtract from the volume drained to determine accurate urinary output.Closed intermittent irrigation does not require the use of sterile gloves.The typical amount of irrigant used is 30 to 50 mL and the tubing is clamped during the process.

Question 14

Which activities related to urinary elimination may be delegated to a nursing assistive personnel (NAP)?

Accepted Answer

Nursing assistive personnel (NAP)may position the patient,focus lighting for the procedure,and enhance the patient's comfort during the procedure through measures such as holding the patient's hand or keeping the patient warm.The nurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce the risk for bladder infection.The nurse evaluates possible alternatives to catheter use,and assessment is the responsibility of the nurse.

Question 15

The nurse receives an order to insert a Foley catheter.In obtaining a catheter of the right size,the nurse is aware that large catheters can lead to which complication?

Accepted Answer

Large catheters (larger than 16 Fr)can distend the urethra and permanently damage the urethra and bladder neck,as well as cause bladder spasms and leaking around the catheter.Use a catheter of the smallest size possible to minimize trauma and promote adequate drainage of the periurethral glands.This will decrease the risk for infection.

Question 16

The nurse notes that urine does not flow after a female patient is catheterized.The nurse believes that the catheter has been placed into the vagina.Which action should the nurse take?

Accepted Answer

If no urine appears,check whether the catheter is in the vagina.If misplaced,leave the catheter in the vagina as a landmark indicating where not to insert it,and insert another catheter into the meatus.Reinserting a catheter that has already been contaminated by vaginal exposure could lead to urinary tract infection.

Question 17

Which symptom is the patient with fluid overload likely to exhibit?

Accepted Answer

Cardiovascular signs of fluid volume excess include bounding pulse rate,normal blood pressure with or without orthostatic changes,third heart sound (S?),and distended neck veins.Oliguria is a renal sign of fluid volume deficit.Increased skin temperature is a sign of fluid volume deficit.Increased urine specific gravity is a renal sign of fluid volume deficit.

Question 18

Antimicrobial catheters coated with silver or antibiotics have been shown to reduce the incidence of ________________.

Accepted Answer

The answer of Antimicrobial catheters coated with silver or antibiotics...

Question 19

The nurse has inserted an indwelling catheter and secured the catheter to the patient's thigh,making sure that there is enough slack that movement will not create tension on the catheter.The nurse understands that the chief purpose of properly securing Foley catheters is to obtain which outcome? (Select all that apply. )

Accepted Answer

Securing the catheter will minimize accidental dislodgment.It also will minimize risks for bleeding,trauma,meatal necrosis,and bladder spasms from pressure and traction.

Question 20

The nurse is assessing a patient whose 24-hour output is 2400 mL.Which finding reflects the nurse's understanding of urine output?

Accepted Answer

The average output range for adult urinary output averages between 2200 and 2700 mL in 24 hours.

Quiz 34: Urinary Elimination