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Nurse Exam 2 > 113 L; Exam 2 > Flashcards

113 L; Exam 2 Flashcards

Elimination

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1
Q

What are nursing interventions to promote urinary elimination?

A
  • Support voiding habits
  • Fluid intake
  • Strengthening Muscle tone
  • Stimulating urination
  • resolving urinary retention
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2
Q

How can a nurse maintain regular voiding habits?

A
  • Schedule: Creating routine
  • Urge to void: assist the patient to void
    when the patient first feels the urge
  • Privacy
  • Position: allow patients to void in
    preferred position
  • Hygiene: prevention of infection
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3
Q

How can a nurse promote fluid intake?

A
  • Encourage 6-8 oz of liquids a day
  • Provide fresh water, juices, and fluids
  • Reminding confused patients to drink
  • Monitor fluid intake for excessive amounts of caffeine-containing beverages, high-sodium beverages, and high-sugar beverages
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4
Q

How much should a healthy adult drink in a day?

A

6-8 oz glasses of liquid

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5
Q

(TRUE OR FALSE) Does drinking 6-8 oz of liquid cause water retention and contribute to weight gain?

A

FALSE-

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6
Q

What should a nurse look out for in patients with weakened pelvic floor muscles?

A
  • Urinary continence problems
  • stress incontinence
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7
Q

What interventions should a nurse include to promote muscle tone?

A
  • Pelvic floor muscle training/ Kegel
    exercises
  • Ambulation
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8
Q

How should a nurse assist with toileting?

A
  • Note abnormalities of urine (if warranted)
  • Calculating urine volume (if warranted)
  • Providing a commode
  • Bedpan and Urinal
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8
Q
A
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8
Q

People most at risk for UTI?

A

-FEMALES (Sexually active or poorly educate on hygiene techniques)
Why?
Females have a shorter urethrae
compared to males, so they are
more susceptible to infection.

  • Postmenopausal people:
    Why?
    Decreased estrogen affects the
    vaginal microbiome.

-Patients with indwelling catheter

  • People with diabetes
  • Older adults
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8
Q
A
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9
Q

(TRUE OR FALSE)
It is okay for weakened patients with fall risk to lock the bathroom when voiding.

A

False

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9
Q

What is the most common bacteria for UTI?

A

Escherichia coli

Why?
Transmitted through contact, found in the GI track.
Common way it is transmitted, is through poor hygiene technique.

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9
Q

Which patients should a nurse assist with toileting?

A
  • Weakened patients
  • Cognitive impairments
  • Post-operative or recovering
  • Are using assistive devices
  • Experience incontinence or bowel/bladder control issues
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9
Q

What are self care behaviors that help with urine elimination?

A
  • Maintaining voiding pattern and volume
  • Respond as soon as possible to the urge
    to void
  • Drink 6-8 oz glasses of water daily
  • Avoid foods that contain excess sodium
  • Monitor use of caffeine, alcohol, or medication schedules
    -Seek medical assistance for any change in urine characteristics/ pain
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10
Q

What are Age-related changes

A
  • Nocturia, frequency and urgency
  • Incontinence
  • UTIs
11
Q

Nursing strategies for Nocturia, frequency and urgency

A
  • Easy access to bathroom or commode
  • Discourage fluid intake at bedtime
  • Discourage alcohol use before bedtime
  • Evaluate medication regimen and schedule, particularly diuretics and drugs that produce sedation or confusion
    -Use a night light
    -Use clothing that is easily removed fore voiding
  • Keep assistive ambulatory devices readily and available
  • evaluate gait and ability to ambulate safely
  • Assess for urinary tract infections
12
Q

Nursing strategies for Incontinence

A
  • Maintain a fluid intake
  • Discourage use of alcohol, artificial
    sweeteners, and caffeine
  • provide easy access to the bathroom
  • use assistive devices when necessary
  • Assess factors that influence voiding
  • Use collection devices when necessary
  • ensure safety when ambulating
  • encourage use of whole, unprocessed, coarse wheat bran to prevent constipation and fecal impaction
  • perform pelvic floor muscle training(PFMT)
  • Encourage participation in a bladder retaining program
13
Q
  1. What is the primary purpose of urination?( select ONE)

A. To regulate body temperature
B. To remove wastes and toxins from the body
C. To control electrolyte levels in the blood
D. To regulate blood pressure

A

Answer: B. To remove wastes and toxins from the body

14
Q

A nurse is assessing a patient with kidney disease. Which urinary output observation would indicate dehydration?

A. Specific gravity of 1.030
B. Pale yellow urine
C. Cloudy urine
D. Sweet-smelling urine

A

A. Specific gravity of 1.030

15
Q

What is a typical characteristic of urine in infants?

A. Infrequent urination
B. High concentration of urine
C. Control of sphincters by 6 months
D. 6-8 wet diapers per day

A

D. 6-8 wet diapers per day

16
Q

Which condition might a nurse expect in an elderly patient who reports waking up frequently to urinate?

A. Urinary incontinence
B. Enuresis
C. Nocturia
D. Dysuria

A

C. Nocturia

17
Q

Which of the following may cause a patient’s urine to appear orange-red in color?

A. Phenazopyridine
B. Ibuprofen
C. Antibiotics
D. Antidepressants

A

A. Phenazopyridine

18
Q
  1. A patient is taking amitriptyline. Which urine color would the nurse expect to observe?

A. Orange
B. Green or blue-green
C. Brown or black
D. Pale yellow

A

B. Green or blue-green

19
Q
  1. What dietary component can lead to acidic urine?

A. Dairy products
B. High-protein diet
C. Citrus fruits
D. Vegetables

A

B. High-protein diet

20
Q
  1. A patient has cloudy urine on their urinalysis. Which of the following might the nurse suspect?

A. Dehydration
B. Presence of RBCs or WBCs
C. High protein diet
D. Low pH

A

B. Presence of RBCs or WBCs

21
Q
  1. Which developmental milestone is typical for a 2-year-old child regarding urination?

A. Full urinary control
B. Voluntary sphincter control
C. Nighttime bladder control
D. Toilet training completed

A

B. Voluntary sphincter control

22
Q

Which of the following is an expected finding in a patient with autonomic bladder?

A. Involuntary urination due to loss of control by the brain
B. Difficulty initiating urination due to muscle weakness
C. Frequent urination caused by excess caffeine intake
D. Painful urination due to inflammation

A

A. Involuntary urination due to loss of control by the brain

23
Q

A patient with a UTI reports painful urination. What term best describes this symptom?

A. Polyuria
B. Dysuria
C. Oliguria
D. Enuresis

A

B. Dysuria

24
Q

Which food is most likely to cause a strong, musty odor in urine?

A. Asparagus
B. Citrus fruits
C. Meat
D. Dairy products

A

A. Asparagus

25
Q

A nurse is caring for a patient with a urinary catheter. What is a primary reason for assessing this patient’s muscle tone?

A. To determine fluid intake needs
B. To evaluate bladder control after catheter removal
C. To prevent nocturia
D. To assess for potential UTIs

A

B. To evaluate bladder control after catheter removal

26
Q

Which patient would a nurse prioritize for assessing urinary elimination patterns?

A. A patient with stable blood pressure
B. A patient on high doses of nephrotoxic antibiotics
C. A patient with normal specific gravity levels
D. A patient without recent changes in fluid intake

A

B. A patient on high doses of nephrotoxic antibiotics

27
Q

A nurse is teaching a patient about maintaining normal urine pH. Which dietary recommendation is most appropriate?

A. Increase intake of dairy products
B. Decrease protein intake
C. Eat more acidic foods, such as citrus fruits
D. Focus on high-sodium foods

A

B. Decrease protein intake

28
Q

A nurse assesses a patient’s urine and notes it is clear and translucent. What does this observation most likely indicate?

A. Dehydration
B. A normal finding in fresh urine
C. High specific gravity
D. The presence of infection

A

B. A normal finding in fresh urine

29
Q

Which of the following is the best nursing action for a 2-year-old child starting toilet training?

A. Encourage toilet training only after the child is consistently dry during the day and night
B. Limit fluids after meals to reduce accidents
C. Start toilet training when the child shows signs of sphincter control
D. Use rewards each time the child sits on the toilet, regardless of success

A

C. Start toilet training when the child shows signs of sphincter control

30
Q

A patient’s urinalysis shows a pH of 7.5. Which diet is most likely contributing to this finding?

A. High-protein diet
B. Dairy and vegetable-rich diet
C. High meat consumption
D. Low fruit and vegetable intake

A

B. Dairy and vegetable-rich diet

31
Q

Which of the following symptoms should prompt a nurse to assess for urinary retention?

A. Urine color changes
B. Frequent, small amounts of urine
C. Strong odor in urine
D. Urinary incontinence

A

B. Frequent, small amounts of urine

32
Q
A

Nurse Exam 2 (1 decks)

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