Deck 0 - Elimination

Question 1

If obstructed, which component of the urination system would cause peristaltic waves?

1. Kidney
2. Ureters
3. Bladder
4. Urethra

Answer 1

2. Ureters

Rationale:

Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur.

Question 2

When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding?

1. Glomerular filtration rate of 20 mL/min
2. Urine output of 80 mL/hr
3. pH of 6.4
4. Protein level of 2 mg/100 mL

Answer 2

1. Glomerular filtration rate of 20 mL/min

Rationale:

Normal glomerular filtration rate should be around 125 mL/min; a severe decrease in renal perfusion could indicate a life-threatening problem such as shock or dehydration. Normal urine output is 1000 to 2000 mL/day; an output of 30 mL/hr or less for 2 or more hours would be cause for concern. 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.

Question 3

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

1. Increase the patient’s intravenous fluid rate.
2. Encourage the patient to drink caffeinated beverages.
3. Assess for bladder distention.
4. Request an order for diuretics.

Answer 3

3. Assess for bladder distention.

Rationale:

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 4

A patient requests the nurse’s assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient’s inability to void because

1. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void.
2. The patient does not recognize the physiological signals that indicate a need to void.
3. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention.
4. The patient is not drinking enough fluids to produce adequate urine output.

Answer 4

1. Anxiety can make 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. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological or psychological condition exists.

Question 5

The nurse knows that indwelling catheters are placed before a cesarean because

1. The patient may void uncontrollably during the procedure.
2. A full bladder can cause the mother’s heart rate to drop.
3. Spinal anesthetics can temporarily disable urethral sphincters.
4. The patient will not interrupt the procedure by asking to go to the bathroom.

Answer 5

3. Spinal anesthetics can temporarily disable urethral sphincters.

Rationale:

Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother.

Question 6

The nurse knows that urinary tract infection (UTI) is the most common health care–associated infection because

1. Catheterization procedures are performed more frequently than indicated.
2. Escherichia coli pathogens are transmitted during surgical or catheterization procedures.
3. Perineal care is often neglected by nursing staff.
4. Bedpans and urinals are not stored properly and transmit infection.

Answer 6

2. Escherichia coli pathogens are transmitted during surgical or catheterization procedures.

Rationale:

E. coli is the leading pathogen causing UTIs; this pathogen enters during procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the greatest cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently. Bedpans and urinals are not inserted into the urinary tract, so they are unlikely to be the primary cause of UTI.

Question 7

An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which nursing diagnosis should the nurse include in the patient’s plan of care?

1. Urinary retention
2. Hesitancy
3. Urgency
4. Urinary incontinence

Answer 7

4. Urinary incontinence

Rationale:

Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine known as Urinary incontinence. Urinary retention is the inability to empty the bladder. Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of the need to void immediately.

Question 8

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

1. Clear the path to the bathroom of all obstacles before bed.
2. Leave the bathroom light on to illuminate a pathway.
3. Limit fluid and caffeine intake before bed.
4. Practice Kegel exercises to strengthen bladder muscles.

Answer 8

3. Limit fluid and caffeine intake before bed.

Rationale:

Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. Clearing a path to the restroom or illuminating the path, or shortening the distance to the restroom, may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing incontinence.

Question 9

When caring for a patient with urinary retention, the nurse would anticipate an order for

1. Limited fluid intake.
2. A urinary catheter.
3. Diuretic medication.
4. A renal angiogram.

Answer 9

2. A urinary catheter.

Rationale:

A urinary catheter would relieve urinary retention. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. A renal angiogram is an inappropriate diagnostic test for urinary retention.

Question 10

Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking

1. “When was the last time you voided?”
2. “Do you lose urine when you cough or sneeze?”
3. “Have you noticed any change in your urination patterns?”
4. “Do you have a fever or chills?”

Answer 10

1. “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. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, changing urination patterns, and losing urine during coughing or sneezing focus on specific pathological conditions.

Question 11

Which of the following is the primary function of the kidney?

1. Metabolizing and excreting medications
2. Maintaining fluid and electrolyte balance
3. Storing and excreting urine
4. Filtering blood cells and proteins

Answer 11

2. Maintaining fluid and electrolyte balance

Rationale:

The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin.

Question 12

While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find

1. An indwelling Foley catheter.
2. Reddened irritated skin on the buttocks.
3. Tiny blood clots in the patient’s urine.
4. Foul-smelling discharge indicative of a UTI.

Answer 12

2. Reddened irritated skin on the 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.

Question 13

Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse’s first priority?

1. Self-care deficit related to decreased mobility
2. Risk of infection
3. Anxiety related to urinary frequency
4. Impaired self-esteem related to lack of independence

Answer 13

2. Risk of infection

Rationale:

Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow’s hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self-esteem. Decreased mobility can lead to self-care deficit; the nurse’s priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene.

Question 14

A patient asks about treatment for urge urinary incontinence. The nurse’s best response is to advise the patient to

1. Perform pelvic floor exercises.
2. Drink cranberry juice.
3. Avoid voiding frequently.
4. Wear an adult diaper.

Answer 14

1. 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. 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 15

The nurse suspects that a urinary tract infection has progressed to cystitis when the patient complains of which symptom?

1. Dysuria
2. Flank pain
3. Frequency
4. Fever and chills

Answer 15

3. Frequency

Rationale:

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

Question 16

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

1. “Does your bladder feel distended?”
2. “Do you empty your bladder completely when you void?”
3. “Do you experience urine leakage when you cough or sneeze?”
4. “Do your symptoms increase with consumption of alcohol or caffeine?”

Answer 16

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

Rationale:

Stress incontinence can be related to intra-abdominal pressure causing urine leakage, as would happen during coughing or sneezing. Asking the patient about the fullness of his 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 17

When establishing a diagnosis of altered urinary elimination, the nurse should first

1. Establish normal voiding patterns for the patient.
2. Encourage the patient to flush kidneys by drinking excessive fluids.
3. Monitor patients’ voiding attempts by assisting them with every attempt.
4. Discuss causes and solutions to problems related to micturition.

Answer 17

4. Discuss causes and solutions to problems related to micturition.

Rationale:

The nurse should assess first to determine cause, then should discuss and create goals with the patient, so nurse and patient can work in tandem to normalize voiding. The nurse should incorporate the patient’s input into creating a plan of care for the patient. Drinking excessive fluid will not help and may worsen alterations in urinary elimination. The nurse does not need to monitor every void attempt by the patient; instead the nurse should provide patient education. The nurse asks the patient about normal voiding patterns, but establishing voiding patterns is a later intervention.

Question 18

To obtain a clean-voided urine specimen for a female patient, the nurse should teach the patient to

1. Cleanse the urethral meatus from the area of most contamination to least.
2. Initiate the first part of the urine stream directly into the collection cup.
3. Hold the labia apart while voiding into the specimen cup.
4. Drink fluids 5 minutes before collecting the urine specimen.

Answer 18

3. 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 steam flushes out microorganisms in the urethra and prevents bacterial transmission in the specimen. Drink fluids 30 to 60 minutes before giving a specimen.

Question 19

When viewing a urine specimen under a microscope, what would the nurse expect to see in a patient with a urinary tract infection?

1. Bacteria
2. Casts
3. Crystals
4. Protein

Answer 19

1. Bacteria

Rationale:

Bacteria indicate a urinary tract infection. Crystals would be seen with renal stone formation. Casts indicate renal alterations. Protein is not visible under a microscope and indicates renal disease.

Question 20

The nurse would expect the urine of a patient with uncontrolled diabetes mellitus to be

1. Cloudy.
2. Discolored.
3. Sweet smelling.
4. Painful.

Answer 20

3. Sweet smelling.

Rationale:

Incomplete fat metabolism and buildup of ketones give urine a sweet or fruity odor. Cloudy urine may indicate infection or renal failure. Discolored urine may result from various medications. Painful urination indicates an alteration in urinary elimination.

Question 21

What signs and symptoms would the nurse expect to observe in a patient with excessive white blood cells present in the urine?

1. Fever and chills
2. Difficulty holding in urine
3. Increased blood pressure
4. Abnormal blood sugar

Answer 21

1. Fever and chills

Rationale:

The presence of white blood cells in urine indicates a urinary tract infection. Difficulty with urinary elimination indicates blockage or renal damage. 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, as this finding indicates diabetes.

Question 22

The nurse would anticipate an order for which diagnostic test for a patient who has severe flank pain and calcium phosphate crystals revealed on urinalysis?

1. Renal ultrasound
2. Bladder scan
3. KUB x-ray
4. Intravenous pyelogram

Answer 22

4. 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 renal ultrasound is performed to identify gross structures. A bladder scan measures the amount of urine in the bladder. A KUB x-ray shows size, shape, symmetry, and location of the kidneys.

Question 23

A nurse is caring for a patient who just underwent intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’s first priority in caring for this patient?

1. Turn the patient on the right side to alleviate pressure on the left kidney.
2. Encourage the patient to increase fluid intake to flush the obstruction.
3. Administer narcotic medications to alleviate pain.
4. Monitor the patient for fever, rash, and difficulty breathing.

Answer 23

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

Rationale:

Intravenous pyelography is performed by administering iodine-based dye to view functionality of the urinary system. Many individuals are allergic to shellfish; 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.

Question 24

Which statement by the patient about an upcoming computed tomography (CT) scan indicates a need for further teaching?

1. “I’m allergic to shrimp, so I should monitor myself for an allergic reaction.”
2. “I will complete my bowel prep program the night before the scan.”
3. “I will be anesthetized so that I lie perfectly still during the procedure.”
4. “I will ask the technician to play music to ease my anxiety.”

Answer 24

3. “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. Patients need to be assessed for an allergy to shellfish if receiving contrast for the CT. Bowel cleansing is often performed before CT. Listening to music will help the patient relax and remain still during the examination.

Question 25

The nurse anticipates preparing a patient who is allergic to shellfish for an arteriogram by

1. Obtaining baseline vital signs after the start of the procedure.
2. Monitoring the extremity for neurocirculatory function.
3. Keeping the patient on bed rest for the prescribed time.
4. Administering an antihistamine medication to the patient.

Answer 25

4. Administering an antihistamine medication to the patient.

Rationale:

Before the procedure is begun, the nurse should assess the patient for food and other allergies and should administer an antihistamine, because a contrast iodine-based dye is used for the procedure. Baseline vitals should be obtained before the start of the procedure and frequently thereafter. The procedure site is monitored and the patient kept on bed rest after the procedure is complete.

Question 26

A nurse anticipates urodynamic testing for a patient with which symptom?

1. Involuntary urine leakage
2. Severe flank pain
3. Presence of blood in urine
4. Dysuria

Answer 26

1. Involuntary urine leakage

Rationale:

Urodynamic testing evaluates the muscle function of the bladder and is used to look for the cause of urinary incontinence. Severe flank pain indicates renal calculi; CT scan or IVP would be a more efficient diagnostic test. Blood indicates trauma to the urethral or bladder mucosa. Pain on elimination may warrant cultures to check for infection.

Question 27

A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To stimulation micturition, which nursing intervention should the nurse try first?

1. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the patient’s progress
2. Utilizing the power of suggestion by turning on the faucet and letting the water run
3. Obtaining an order for a Foley catheter
4. Administering diuretic medication

Answer 27

2. 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.

Question 28

A nurse is caring for an 8-year-old patient who is embarrassed about urinating in his bed at night. Which intervention should the nurse suggest to reduce the frequency of this occurrence?

1. “Drink your nightly glass of milk earlier in the evening.”
2. “Set your alarm clock to wake you every 2 hours, so you can get up to void.”
3. “Line your bedding with plastic sheets to protect your mattress.”
4. “Empty your bladder completely before going to bed.”

Answer 28

1. “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.

Question 29

Many individuals have difficulty voiding in a bedpan or urinal while lying in bed because they

1. Are embarrassed that they will urinate on the bedding.
2. Would feel more comfortable assuming a normal voiding position.
3. Feel they are losing their independence by asking the nursing staff to help.
4. Are worried about acquiring a urinary tract infection.

Answer 29

2. Would feel more comfortable assuming a normal voiding position.

Rationale:

Assuming a normal voiding position helps patients relax and be able to void; lying in bed is not the typical position in which people void. Men usually are most comfortable when standing; women are more comfortable when sitting and squatting. Embarrassment at using the bedpan and worrying about a urinary tract infection are not related to the lying-in-bed position. Fear of loss of independence is not related to use of the bedpan or urinal.

Question 30

The nurse would anticipate inserting a Coudé catheter for which patient?

1. An 8-year-old male undergoing anesthesia for a tonsillectomy
2. A 24-year-old female who is going into labor
3. A 56-year-old male admitted for bladder irrigation
4. An 86-year-old female admitted for a urinary tract infection.

Answer 30

3. 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.

Question 31

The nurse knows that which indwelling catheter procedure places the patient at greatest risk for acquiring a urinary tract infection?

1. Emptying the drainage bag every 8 hours or when half full
2. Kinking the catheter tubing to obtain a urine specimen
3. Placing the drainage bag on the side rail of the patient’s bed
4. Failing to secure the catheter tubing to the patient’s thigh

Answer 31

3. Placing the drainage bag on the side rail of the patient’s bed

Rationale:

Placing the drainage bag on the side rail of the bed could allow the bag to be raised above the level of the bladder and urine to flow back into the bladder. The urine in the drainage bag is a medium for bacteria; allowing it to reenter the bladder can cause infection. The drainage bag should be emptied and output recorded every 8 hours or when needed. Urine specimens are obtained by temporarily kinking the tubing; a prolonged kink could lead to bladder distention. Failure to secure the catheter to the patient’s thigh places the patient at risk for tissue injury from catheter dislodgment.

Question 32

A nurse notifies the provider immediately if a patient with an indwelling catheter

1. Complains of discomfort upon insertion of the catheter.
2. Places the drainage bag higher than the waist while ambulating.
3. Has not collected any urine in the drainage bag for 2 hours.
4. Is incontinent of stool and contaminates the external portion of the catheter.

Answer 32

3. Has not collected any urine in the drainage bag for 2 hours.

Rationale:

If the patient has not produced urine in 2 hours, the physician needs to be notified immediately because this could indicate renal failure. Discomfort upon catheter insertion is unpleasant but unavoidable. The nurse is responsible for maintaining the integrity of the catheter by ensuring that the drainage bag is below the patient’s bladder. Stool left on the catheter can cause infection and should be removed as soon as it is noticed. The nurse should ensure that frequent perineal care is being provided.

Question 33

The nurse would question an order to insert a urinary catheter on which patient?

1. A 26-year-old patient with a recent spinal cord injury at T2
2. A 30-year-old patient requiring drug screening for employment
3. A 40-year-old patient undergoing bladder repair surgery
4. An 86-year-old patient requiring monitoring of urinary output for renal failure

Answer 33

2. A 30-year-old patient requiring drug screening for employment

Rationale:

Urinary catheterization places the patient at increased risk for infection and should be performed only when necessary. Urine can be obtained via clean-catch technique for a drug screening or urinalysis. Spinal cord injury, surgery, and renal failure with critical intake and output monitoring are all appropriate reasons for catheterization.

Question 34

When caring for a hospitalized patient with a urinary catheter, which nursing action best prevents the patient from acquiring an infection?

1. Inserting the catheter using strict clean technique
2. Performing hand hygiene before and after providing perineal care
3. Fully inflating the catheter’s balloon according to the manufacturer’s recommendation
4. Disconnecting and replacing the catheter drainage bag once per shift

Answer 34

2. Performing hand hygiene before and after providing perineal care

Rationale:

Hand hygiene helps prevent infection in patients with a urinary catheter. A catheter should be inserted in the hospital setting using sterile technique. Inflating the balloon fully prevents dislodgement and trauma, not infection. Disconnecting the drainage bag from the catheter creates a break in the system and an open portal of entry and increases risk of infection.

Question 35

An 86-year-old patient asks the nurse what lifestyle changes will reduce the chance of a urinary tract infection. Which response is accurate?

1. Urinary tract infections are unavoidable in the elderly because of a weakened immune system.
2. Decreasing fluid intake will decrease the amount of urine with bacteria produced.
3. Making sure to cleanse the perineal area from back to front after voiding will reduce the chance of infection.
4. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

Answer 35

4. Increasing consumption of acidic foods such as cranberry juice will reduce the chance of infection.

Rationale:

Cranberry juice and other acidic foods decrease adherence of bacteria to the bladder wall. Urinary tract infections are avoidable in the elderly population with proper knowledge and hygiene. Perineal skin should be cleansed from front to back to avoid spreading fecal matter to the urethra. Increasing fluids will help to flush bacteria, thus preventing them from residing in the bladder for prolonged periods of time.

Question 36

A nurse is providing education to a patient being treated for a urinary tract infection. Which of the following statements by the patient indicates an understanding?

1. “Since I’m taking medication, I do not need to worry about proper hygiene.”
2. “I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out.”
3. “My medication may discolor my urine; this should resolve once the medication is stopped.”
4. “I should not have sexual intercourse until the infection has resolved.”

Answer 36

3. “My medication may discolor my urine; this should resolve once the medication is stopped.”

Rationale:

Some anti-infective medications turn urine colors; this is normal and will dissipate as the medication leaves the system. Even if the patient is on medication, hygiene is important to prevent spread or reinfection. Fluid intake should be increased to help flush out bacteria; however, 15 to 20 glasses is too much. Sexual intercourse is allowed with a urinary tract infection, as long as good hygiene and safe practices are used.

Question 37

To reduce patient discomfort during closed catheter irrigation, the nurse should

1. Use room temperature irrigation solution.
2. Administer the solution as quickly as possible.
3. Allow the solution to sit in the bladder for at least 1 hour.
4. Raise the bag of irrigation solution at least 12 inches above the bladder.

Answer 37

1. Use room temperature irrigation solution.

Rationale:

Using cold solutions, instilling solutions too quickly, and prolonging filling of the bladder can cause discomfort and cramping. To reduce this, ensure that the solution is at room temperature, lower the solution bag so it instills slowly, and drain the bladder fully after an ordered amount of time.

Question 38

Which observation by the nurse best indicates that bladder irrigation for urinary retention has been effective?

1. Recording an output that is larger than the amount instilled
2. Presence of blood clots or sediment in the drainage bag
3. Reduction in discomfort from bladder distention
4. Visualizing clear urinary catheter tubing

Answer 38

1. Recording an output that is larger than the amount instilled

Rationale:

Recording an output that is greater than what was irrigated into the bladder shows progress that the bladder is draining urine. The other observations do not objectively measure the increase in urine output.

Question 39

The nurse anticipates urinary diversion from the kidneys to a site other than the bladder for which patient?

1. A 12-year-old female with severe abdominal trauma
2. A 24-year-old male with severe genital warts around the urethra
3. A 50-year-old male with recent prostatectomy
4. A 75-year-old female with end-stage renal disease

Answer 39

1. A 12-year-old female with severe abdominal trauma

Rationale:

Urinary diversion would be needed in a patient with abdominal trauma who might have injury to the urinary system. Genital warts are not needed for urinary diversion. Patients with a prostatectomy may require intermittent catheterization after the procedure. End-stage renal disease would not be affected by rerouting the flow of urine.

Question 40

Which nursing actions are acceptable when collecting a urine specimen? (Select all that apply.)

1. Growing urine cultures for up to 12 hours
2. Labeling all specimens with date, time, and initials
3. Wearing gown, gloves, and mask for all specimen handling
4. Allowing the patient adequate time and privacy to void
5. Squeezing urine from diapers into a urine specimen cup
6. Transporting specimens to the laboratory in a timely fashion
7. Placing a plastic bag over the child’s urethra to catch urine

Answer 40

2. Labeling all specimens with date, time, and initials
3. Allowing the patient adequate time and privacy to void
4. Transporting specimens to the laboratory in a timely fashion
5. Placing a plastic bag over the child’s urethra to catch urine

Rationale:

All specimens should be labeled appropriately and processed in a timely fashion. Allow patients time and privacy to void. Children may have difficulty voiding; attaching a plastic bag gives the child more time and freedom to void. Urine cultures can take up to 48 hours to develop. Gown, gloves, and mask are not necessary for specimen handling unless otherwise indicated. Urine should not be squeezed from diapers.

Question 41

The nurse properly obtains a 24-hour urine specimen collection by (Select all that apply.)

1. Asking the patient to void and to discard the first sample.
2. Keeping the urine collection container on ice.
3. Withholding all patient medications for the day.
4. Asking the patient to notify the staff before and after every void.

Answer 41

1. Asking the patient to void and to discard the first sample.
2. Keeping the urine collection container on ice.

Rationale:

When obtaining a 24-hour urine specimen, it is important to keep the urine in cool condition. The patient should be asked to void and to discard the urine before the procedure begins. Medications do not need to be held unless indicated by the provider. If properly educated about the collection procedure, the patient can maintain autonomy and perform the procedure alone, taking care to maintain the integrity of the solution.

Question 42

Which of the following are indications for irrigating a urinary catheter? (Select all that apply.)

1. Sediment occluding within the tubing
2. Blood clots in the bladder following surgery
3. Rupture of the catheter balloon
4. Bladder infection
5. Presence of renal calculi

Answer 42

1. Sediment occluding within the tubing
2. Blood clots in the bladder following surgery
3. Bladder infection

Rationale:

Catheter irrigation is used to flush and remove blockage that may be impeding the catheter from properly draining the bladder. Irrigation is used to remove blood clots in the bladder following surgery. For patients with bladder infection, an antibiotic irrigation is often ordered. A ruptured catheter balloon will involve extensive follow-up and possible surgery to remove the particles. Renal calculi obstruct the ureters and therefore the flow of urine before it reaches the bladder.

Question 43

Which of the following symptoms are most closely associated with uremic syndrome? (Select all that apply.)

1. Fever
2. Nausea and vomiting
3. Headache
4. Altered mental status
5. Dysuria

Answer 43

2. Nausea and vomiting
3. Headache
4. Altered mental status

Rationale:

Uremic syndrome is associated with end-stage renal disease. Signs and symptoms include headache, altered mental status, coma, seizures, nausea, vomiting, and pericarditis.

Question 44

The nurse understands that peritoneal dialysis and hemodialysis use which processes to clean the patient’s blood? (Select all that apply.)

1. Gravity
2. Osmosis
3. Diffusion
4. Filtration

Answer 44

2. Osmosis
3. Diffusion

Rationale:

Osmosis and diffusion are the two processes used to clean the patient’s blood in both types of dialysis. In peritoneal dialysis, osmosis and dialysis occur across the semi-permeable peritoneal membrane. In hemodialysis, osmosis and dialysis occur through the filter membrane on the artificial kidney. In peritoneal dialysis, the dialysate flows by gravity out of the abdomen. Gravity has no effect on cleansing of the blood.Filtration is the process that occurs in the glomerulus as blood flows through the kidney.