Deck 1: Urinary Elimination Flashcards Preview

Elimination Module 5 > Deck 1: Urinary Elimination > Flashcards

Flashcards in Deck 1: Urinary Elimination Deck (44)
Loading flashcards...
1

A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine?
a. Kidney, urethra, bladder, ureters
b. Kidney, ureters, bladder, urethra
c. Bladder, kidney, ureters, urethra
d. Bladder, kidney, urethra, ureters

b. Kidney, ureters, bladder, urethra

Rationale:

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

2

A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up?
a. Protein level of 2 mg/100 mL
b. Urine output of 80 mL/hr
c. Specific gravity of 1.036
d. pH of 6.4

c. Specific gravity of 1.036

Rationale:

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.

3

A patient is experiencing oliguria. Which action should the nurse perform first?
a. Assess for bladder distention.
b. Request an order for diuretics.
c. Increase the patient’s intravenous fluid rate.
d. Encourage the patient to drink caffeinated beverages.

a. Assess for bladder distention.

Rationale:

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.

4

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. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.
b. The patient does not recognize the physiological signals that indicate a need to void.
c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention.
d. The patient is not drinking enough fluids to produce adequate urine output.

a. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void.

Rationale:

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.

5

The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action?
a. The patient may void uncontrollably during the procedure.
b. Local trauma sometimes promotes excessive urine incontinence.
c. Anesthetics can decrease bladder contractility and cause urinary retention.
d. The patient will not interrupt the procedure by asking to go to the bathroom.

c. Anesthetics can decrease bladder contractility and cause urinary retention.

Rationale:

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.

6

The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria?
a. Blood in the urine
b. Burning upon urination
c. Immediate, strong desire to void
d. Awakes from sleep due to urge to void

b. Burning upon urination

Rationale:

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.

7

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. Functional urinary incontinence
b. Urge urinary incontinence
c. Impaired skin integrity
d. Urinary retention

b. Urge urinary incontinence

Rationale:

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 integritycan occur, it is not the priority at this time, and there is no data to support this diagnosis.

8

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?
a. Limit fluid and caffeine intake before bed.
b. Leave the bathroom light on to illuminate a pathway.
c. Practice Kegel exercises to strengthen bladder muscles.
d. Clear the path to the bathroom of all obstacles before bedtime.

a. Limit fluid and caffeine intake before bed.

Rationale:

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.

9

A nurse is caring for a male patient with urinary retention. Which action should the nurse take first?
a. Limit fluid intake.
b. Insert a urinary catheter.
c. Assist to a standing position.
d. Ask for a diuretic medication.

c. Assist to a standing position.

Rationale:

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.

10

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. Which question is most appropriate?
a. “Does your urinary problem interfere with any activities?”
b. “Do you lose urine when you cough or sneeze?”
c. “When was the last time you voided?”
d. “Are you experiencing a fever or chills?”

c. “When was the last time you voided?”

Rationale:

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.

11

A nurse is planning care for a group of patients. Which task will the nurse assign to the nursing assistive personnel?
a. Obtaining a midstream urine specimen
b. Interpreting a bladder scan result
c. Inserting a straight catheter
d. Irrigating a catheter

a. Obtaining a midstream urine specimen

Rationale:

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.

12

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?
a. An indwelling Foley catheter
b. Reddened irritated skin on buttocks
c. Tiny blood clots in the patient’s urine
d. Foul-smelling discharge indicative of infection

b. Reddened irritated skin on buttocks

Rationale:

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.

13

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. Throw the catheter way and begin again.
b. Fill the balloon with the recommended sterile water.
c. Remove the catheter, wipe with alcohol, and reinsert after lubrication.
d. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.

d. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.

Rationale:

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.

14

A patient asks about treatment for stress urinary incontinence. Which is the nurse’s best response?
a. Perform pelvic floor exercises.
b. Avoid voiding frequently.
c. Drink cranberry juice.
d. Wear an adult diaper.

a. Perform pelvic floor exercises.

Rationale:

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.

15

The nurse suspects cystitis related to a lower urinary tract infection. Which clinical manifestation does the nurse expect the patient to report?
a. Dysuria
b. Flank pain
c. Frequency
d. Fever

c. Frequency

Rationale:

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).

16

Which assessment question should the nurse ask if stress incontinence is suspected?
a. “Do you think your bladder feels distended?”
b. “Do you empty your bladder completely when you void?”
c. “Do you experience urine leakage when you cough or sneeze?”
d. “Do your symptoms increase with consumption of alcohol or caffeine?”

c. “Do you experience urine leakage when you cough or sneeze?”

Rationale:

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.

17

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.
a. 3, 2, 6, 1, 5, 4
b. 5, 6, 1, 2, 3, 4
c. 1, 5, 6, 3, 2, 4
d. 6, 5, 1, 3, 2, 4

d. 6, 5, 1, 3, 2, 4

Rationale:

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.

18

To obtain a clean-voided urine specimen from a female patient, what should the nurse teach the patient to do?
a. Cleanse the urethral meatus from the area of most contamination to least.
b. Initiate the first part of the urine stream directly into the collection cup.
c. Drink fluids 5 minutes before collecting the urine specimen.
d. Hold the labia apart while voiding into the specimen cup.

d. Hold the labia apart while voiding into the specimen cup.

Rationale:

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.

19

A nurse is reviewing results from a urine specimen. What will the nurse expect to see in a patient with a urinary tract infection?
a. Casts
b. Protein
c. Crystals
d. Bacteria

d. Bacteria

Rationale:

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.

20

The patient is taking phenazopyridine. When assessing the urine, what will the nurse expect?
a. Red color
b. Orange color
c. Dark amber color
d. Intense yellow color

b. Orange color

Rationale:

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.

21

Which clinical manifestation will the nurse expect to observe in a patient with excessive white blood cells present in the urine?
a. Reduced urine specific gravity
b. Increased blood pressure
c. Abnormal blood sugar
d. Fever with chills

d. Fever with chills

Rationale:

Fever and chills may be observed. The presence of white blood cells in urine indicates a urinary tract infection or inflammation. Overhydration, early renal disease, and inadequate antidiuretic hormone secretion reduce specific gravity. Increased blood pressure is associated with renal disease or damage and some medications. Abnormal blood sugars would be seen in someone with ketones in the urine or a patient with diabetes.

22

A patient has severe flank pain. The urinalysis reveals presence of calcium phosphate crystals. The nurse will anticipate an order for which diagnostic test?
a. Intravenous pyelogram
b. Mid-stream urinalysis
c. Bladder scan
d. Cystoscopy

a. Intravenous pyelogram

Rationale:

Flank pain and calcium phosphate crystals are associated with renal calculi. An intravenous pyelogram allows the provider to observe pathological problems such as obstruction of the ureter. A mid-stream urinalysis is performed for a routine urinalysis or if an infection is suspected; a urinalysis was already performed, a mid-stream would not be obtained again. A cystoscopy is used to detect bladder tumors and obstruction of the bladder outlet and urethra. A bladder scan measures the amount of urine in the bladder.

23

A nurse is caring for a patient who just underwent an intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’s first priority in caring for this patient?
a. Turn the patient on the right side to alleviate pressure on the left kidney.
b. Encourage the patient to increase fluid intake to flush the obstruction.
c. Monitor the patient for fever, rash, and difficulty breathing.
d. Administer narcotic medications to the patient for pain.

c. Monitor the patient for fever, rash, and difficulty breathing.

Rationale:

Assess for delayed hypersensitivity to the contrast media. Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Therefore, the first nursing priority is to assess the patient for an allergic reaction that could be life threatening. The nurse should then encourage the patient to drink fluids to flush dye resulting from the procedure. Narcotics can be administered but are not the first priority. Turning the patient on the side will not affect patient safety.

24

Which statement by the patient about an upcoming contrast computed tomography (CT) scan indicates a need for further teaching?
a. “I will follow the food and drink restrictions as directed before the test is scheduled.”
b. “I will be anesthetized so that I lie perfectly still during the procedure.”
c. “I will complete my bowel prep program the night before the scan.”
d. “I will be drinking a lot of fluid after the test is over.”

b. “I will be anesthetized so that I lie perfectly still during the procedure.”

Rationale:

Patients are not put under anesthesia for a CT scan; instead, the nurse should educate patients about the need to lie perfectly still and about possible methods of overcoming feelings of claustrophobia. The other options are correct and require no further teaching. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT scan. Bowel cleansing is often performed before CT scan. Another area to address is food and fluid restriction up to 4 hours prior to the test. After the procedure, encourage fluids to promote dye excretion.

25

The nurse is preparing to test a patient for postvoid residual with a bladder scan. Which action will the nurse take?
a. Measure bladder before the patient voids.
b. Measure bladder within 10 minutes after the patient voids.
c. Measure bladder with head of bed raised to 60 degrees.
d. Measure bladder with head of bed raised to 90 degrees.

b. Measure bladder within 10 minutes after the patient voids.

Rationale:

Measurement should be within 10 minutes of voiding. It is a postvoid so the measurement is after the patient voids and the urine volume is recorded. Patient is supine with head slightly elevated.

26

A nurse is watching a nursing assistive personnel (NAP) perform a postvoid bladder scan on a female with a previous hysterectomy. Which action will require the nurse to follow up?
a. Palpates the patient’s symphysis pubis
b. Wipes scanner head with alcohol pad
c. Applies a generous amount of gel
d. Sets the scanner to female

d. Sets the scanner to female

Rationale:

The nurse will follow up if the NAP sets the scanner to female. Women who have had a hysterectomy should be designated as male. All the rest are correct and require no follow-up. The NAP should palpate the symphysis pubis, the scanner head should be cleaned with an alcohol pad, and a generous amount of gel should be applied.

27

A female patient is having difficulty voiding in a bedpan but states that her bladder feels full. To stimulate micturition, which nursing intervention should the nurse try first?
a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient’s progress.
b. Utilizing the power of suggestion by turning on the faucet and letting the water run.
c. Obtaining an order for a Foley catheter.
d. Administering diuretic medication.

b. Utilizing the power of suggestion by turning on the faucet and letting the water run.

Rationale:

To stimulate micturition, the nurse should attempt noninvasive procedures first. Running warm water or stroking the inner aspect of the upper thigh promotes sensory perception that leads to urination. A patient should not be left alone on a bedpan for 30 minutes because this could cause skin breakdown. Catheterization places the patient at increased risk of infection and should not be the first intervention attempted. Diuretics are useful if the patient is not producing urine, but they do not stimulate micturition.

28

A nurse is caring for an 8-year-old patient who is embarrassed about urinating in bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?
a. “Set your alarm clock to wake you every 2 hours, so you can get up to void.”
b. “Line your bedding with plastic sheets to protect your mattress.”
c. “Drink your nightly glass of milk earlier in the evening.”
d. “Empty your bladder completely before going to bed.”

c. “Drink your nightly glass of milk earlier in the evening.”

Rationale:

Nightly incontinence and nocturia are often resolved by limiting fluid intake 2 hours before bedtime. Setting the alarm clock to wake does not correct the physiological problem, nor does lining the bedding with plastic sheets. Emptying the bladder may help with early nighttime urination but will not affect urine produced throughout the night from late-night fluid intake.

29

A nurse is inserting an indwelling urinary catheter for a male patient. Which action will the nurse take?
a. Hold the shaft of the penis at a 60-degree angle.
b. Hold the shaft of the penis with the dominant hand.
c. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
d. Cleanse the meatus with circular strokes beginning at the meatus and working outward.

d. Cleanse the meatus with circular strokes beginning at the meatus and working outward.

Rationale:

Using the uncontaminated dominant hand, cleanse the meatus with cotton balls/swab sticks, using circular strokes, beginning at the meatus and working outward in a spiral motion. Repeat 3 times using a clean cotton ball/swabstick each time. With the nondominant hand (now contaminated), retract the foreskin (if uncircumcised) and gently grasp the penis at the shaft just below the glans. Hold the shaft of the penis at a right angle to the body.

30

The nurse will anticipate inserting a Coudé catheter for which patient?
a. An 8-year-old male undergoing anesthesia for a tonsillectomy
b. A 24-year-old female who is going into labor
c. A 56-year-old male admitted for bladder irrigation
d. An 86-year-old female admitted for a urinary tract infection

c. A 56-year-old male admitted for bladder irrigation

Rationale:

A Coudé catheter has a curved tip that is used for patients with enlarged prostates. This would be indicated for a middle-aged male who needs bladder irrigation. Coudé catheters are not indicated for children or women.