HESI Urinary Patterns

Question 1

Scenario

Answer 1

And older client is a resident in a long-term care facility. The client has been unable to control the urge to avoid since experiencing a cerebrovascular accident (CVA – stroke) one month ago the client is alert and oriented and has no verbal deficits since the stroke

Question 2

The client reports prior to the stroke getting up five or six times to urinate nightly, but controlled the urge long enough to make it to the bathroom. How should the nurse describe the urinary pattern that the client describing?

Answer 2

Nocturia

Rationale: the specifically refers to avoiding frequently at night. The incidents of bacteria increases greatly in the older male client who has an enlarged prostate, and may also indicate an inability to concentrate urine because of poor blood flow to the kidneys.

Question 3

Since the client now void spontaneously, without recognizing the need to void, how should the nurse document the clients current urinary pattern in the medical chart?

Answer 3

Incontinence
Rationale: incontinence is the involuntary loss of urine. in this case of the client It may be the result of neurologic impairment secondary to stroke.

Question 4

Help manage the clients and Cotton the nurse initiates a bladder training program which instruction should the nurse provide to the UAP who will be helping the client?

Answer 4

Remind the client to avoid every two hours while awake into call for assistance to the bathroom

Rationale: a toileting schedule is an effective means to retrain the bladder. Bladder training should start with voiding every two hours in the daytime, and every four hours at night and then be adapted to the end. Individuals needs the call Bell should be near the client so that he can ring the Belfour assistance to prevent the risk of falling.

Question 5

After several weeks, a bladder training program is unsuccessful in stopping the clients incontinence. The client appears with John and states that he is frustrated at the number of episodes that continue to occur. Which intervention should the nurse include in the clients plan of care?

Answer 5

1. Reports signs of insomnia, due to anxiety.
   Rationale: reports of fatigue, lack of sleep and anxiety, or signs of inability to cope
2. Discuss discuss possible coping strategies.

Rationale: coping skills are needed to deal with stressors that threaten physical and mental well-being

Question 6

Following an episode of incontinence, nurse washes the clients perineal area with mild soap and water in applies of water repellent ointment to the skin. The client spouse is present, and the nurse uses this opportunity to educate them about proper skin, care to prevent breakdown which statement by the client spouse indicates the teaching provided was effective?

Answer 6

Wash the area with mild soap, and water, followed by ointment

Rationale: mild soap and warm water should be used to cleanse the skin falling by a protective ointment. These water repellent ointment help protect the skin from acidic effects of urine.

Question 7

The nursing staff continues with bladder training, but the clients incontinent shows little improvement since bladder training has not been successful. The nurse obtains a prescription to apply an external male catheter which intervention is most appropriate for the nurse to include in the clients plan of care?

Answer 7

Assess for signs of skin breakdown

Rationale: catheters can cause skin breakdown and lead to external infections. It is important to use good hygiene and replace catheter daily silicone catheters will allow for better visualization of penis while catheter is in place even with these preventative measures skin breakdown can occur, and should be assessed frequently to prevent external infection or injury

Question 8

The client is admitted to the acute care facility for minor surgery preoperative prescriptions include the insertion of an indwelling urine catheter. A student nurse is assigned to care for the client. The nurse instructor asks the student nurse to prepare to insert the indwelling catheter under supervision. what is the first step in the proper placement of an indwelling urinary catheter for a male client?

Answer 8

Wash perineal area with soap and water
Rationale: the student nurse should first wash the entire perineal area with soap and water before applying anti-septic or lubricant

Question 9

The nurse reviews factors that may indicate catheter insertion with the student nurse, which physiological change that commonly occurs in adult males may affect insertion of the catheter?

Answer 9

Prostate gland enlargement

Rationale: the prostate gland often begins to enlarge after a male client reaches the age of 40 making the urethral catheterization more difficult, if the gland compresses the urethra

Question 10

The student obtains a 16 French fully catheter from the supply room the student nurse explains the procedure to the client who gets permission to begin. After cleansing the urinary medias the student nurse maintains sterile technique while inserting the catheter into the about 4 inches while inflating the balloon, and the client cries out in obvious pain. What action should the student nurse take?

Answer 10

Deflate the balloon, and insert the catheter farther

Rationale: the catheter has not been inserted for enough, and the pressure of the inflatable balloon in the urethra is painful since the student nurse has maintained a septic technique the balloon can be deflated in the catheter and the catheter inserted farther typically the catheter should be inserted 7 to 9 inches to ensure proper placement in the adult mail

Question 11

The catheter is successfully placed in the bladder with a return of 200 mL of clear, yellow urine the catheter secured, and the client is resting comfortably and documenting the catheter insertion procedure which statement should be included?

Answer 11

16 French fully catheter inserted with return of clear, yellow urine

Rationale: the statement includes the best objective data, including the size of the catheter in the outcome of the procedure, and addition, the nurse should also document how the client tolerated the procedure in the clients condition following completion of this procedure

Question 12

The client returns to the PACU after the surgical procedure. The client has an IV of LR infusing at 125 mL/hour 02 add 2 L/min nasal cannula, and an indwelling catheter attached to a drainage bag

Four hours later, the nurse documents, the clients and/output. The LR solution has been been running for four hours and the nurse administer an IV antibiotic that runs 150 mL of normal saline. The client is still NPO after the procedure.

How does the nurse document the clients intake in milliliters?

Answer 12

650

Rationale: 150 mL times 4 = 500 mL of LR 500 mL +150 mL (antibiotic) = 650 mL 

Question 13

The client is responsive, but confused and frequently pulls out the years urinary catheter the nurse observes obvious and the drainage bag in the presence of several blood clots in the tubing. How should the nurse document the situation situation?

Answer 13

Client is confused and pulls out the fully catheter. Urine is pinkish red with blood clots.

Rationale: this recording is concise, but complete providing objective data that describes the current situation

Question 14

The client met Yuriria continues. Two hours later the client becomes restless and appears to be in pain. The nurse observes that there has been no urinary output during the last two hours which assessment to the nurse complete first?

Answer 14

Evaluate the urinary drainage tubing

Rationale: the client has had no urine output in two hours has been experiencing blood clots in the urine and is an obvious discomfort. The nurse should consider that the catheter tubing is obstructed and assessed for kink or pressure on the tubing that may cause an obstruction the nurse should also know the presence of any observable blood clots which can also obstruct flow. This not invasive, could easily identify and immediately resolve the clients discomfort

Question 15

The nurse is unable to resolve the catheter obstruction, using noninvasive measures and notifies the HCP, who prescribes bladder irrigation to dislodge any blood clots obstructing the urine flow the nurse anticipates that the prescription will include the use of which steel solution to irrigate the catheter?

Answer 15

Normal saline

Rationale: an isotonic saline is a sterile normal solution that can be used for bladder irrigation

Question 16

The RN encourages the student nurse to perform that irrigation. The student prepares a solution, applies gloves clamps to distal tubing and begins to clean the specimen port and the drainage tubing. What action should the nurse take?

Answer 16

Encourage the student nurse to continue maintaining as septic technique

Rationale: the student nurse is performing the procedure correctly. Irrigation may also be performed by opening the connection between the catheter and the drainage tubing, but opening that connection increases the risk of contamination.

Question 17

The student nurse and steals a total of 60 mL of the correct solution and withdraws 40 mL of fluid containing several small blood clots the student nurse Dunn, empties 200 mL from the urinary drainage bag, what urine output should be recorded?

Answer 17

 180
Rationale: the student instilled 20 mL more than what was withdrawn so that amount must be subtracted from the volume emptied from the drainage bag

200 mL -20 mL equals 180 mL

The nurse may instill the irrigant without withdrawing any fluid in that circumstance amount of the arrogant must be subtracted from the amount of fluid, emptied from the drainage bag to obtain an accurate measurement of the client urinary output

Question 18

During the catheter irrigation, the nurse observes that the client still confused and attempts to pull out the urinary catheter, IV and nasal cannula. The nurse considers the use of restraints on the basis, of which rational?

Answer 18

The client is at risk for self injury
Rationale: risk of self injury is a reasonable rationale for the use of physical restraint. However, all other safety measures should be attempted before physically restraining a client.

Question 19

The nurse notifies the HCP and obtain a prescription for wrist restraints. The nurse applies the restraints and plans to monitor the client every 30 minutes which assessments are most important for the nurse to perform at each of these times?

Answer 19

1. Skin integrity of the restrained extremities.
   Rationale: wrist restraints can impede circulation, causing tissue damage under the restraint and distal to the restraint skin integrity and assessment of distal circulation (including pulse, volume color, warmth, and sensation) must be assessed. Every 30 minutes in the restraints must be removed at least every two hours to allow for range of motion
2. Pulse rate and volume in the wrists

Rationale: assessment of distal circulation (including pulse color, warmth, and sensation) must be assessed every 30 minutes and the restraints must be removed at least every two hours to allow for range of motion

Question 20

The clients confusion decreases in 12 hours later, the nurses able to remove the wrist restraints by the third postoperative day no further hematuria or blood clots are observed in the urine. However, the nurse does observe that the urine has developed a cloudy appearance, What action should the nurse implement?

Answer 20

Obtain a sterile, urine specimen

Rationale: urine develops a cloudy appearance when a urinary tract infection has developed. A sterile specimen is needed to detect an infection and identify microorganisms.

Question 21

Realizing that indulging urinary catheters increases the risk of developing a urinary tract infection Which intervention should the nurse implement?

Answer 21

Secure the catheter bag to the bedframe when the client is repositioned on his side

Rationale: securing the catheter to the bedframe, will keep the urine draining with gravity, and will avoid backflow it is also safer to connect to a part of the bed that is not adjustable

Question 22

Your analysis results are as follows: PH 8.5, specific gravity, 1.015, protein 0 g/day glucose 0MMOL/LW8/HPFRBC2/hPF based on the urinalysis results the HCP prescribes a broad spectrum antibiotic after 24 hours of receiving the antibiotics the clients condition has not improved. What additional nursing intervention should the nurse implement?

Answer 22

Provide a glass of cranberry juice daily
Rationale: the pH of the clients urine is elevated, indicating alkaline urine. Cranberry juices to increase the acidity of the urine, providing a less desirable environment for bacterial growth.

Question 23

What diagnostic test results would make the nurse concerned that the client is at risk for sepsis?

Answer 23

Urine culture shows resistance to the prescribed antibiotic

Rationale: if the microorganisms causing the urinary tract infection are resistant to the prescribed antibiotic the antibiotic is an effective and the client is at risk for sepsis or generalized infection

Question 24

After reviewing the clients diagnostic test results, the nurse consult with the HCP and receives a prescription for a new antibiotic since the clients creatinine levels is elevated the nurses concerned about which problem and administering the medication?

Answer 24

Drug toxicity due to reduced drug excretion

Rationale: an elevated creatinine level reflects a problem with the kidneys. If the kidneys are unable to excrete drug molecules efficiently, the drug will remain in the body for a prolonged period of time which may result in drug toxicity.

Question 25

The nurse knows that the medication dosage is in the safe range for older adults, which is to be administered by IV. Every 12 hours the nurse recognizes that the frequency of drug administration is based on which characteristic of this medication?

Answer 25

Half-life

Rationale: half-life describes the length of time required to reduce a drug level to 1/2 of its initial value drugs with short half lives will have to be given more frequently than those with longer half lives

Question 26

The clients and dwelling catheter is removed by the nurse on the morning of the clients anticipated discharge which assessment finding warrants and intervention by the nurse?

Answer 26

The client has not voided in eight hours after catheter removal

Rationale: the nurse should report if the client is unable to void within 6 to 8 hours after catheter removal has sensations of not emptying strains to void or experiences small voiding amounts with increased frequency

Question 27

To encourage voiding, the nurse instruct the UAP to perform which intervention?

Answer 27

Turn on the tap, so water is running when the client attempts to avoid
Rationale: running water, often stimulates the urge to avoid as does placing the clients hands in warm water

Question 28

The client voids after the catheter is removed and is discharged from the acute care facility and transferred to long-term care facility since the client no longer has an IV. The prescription for the antibiotic has changed to an oral medication. The client has some difficulty swallowing and the nurse is considering the best technique to help the client swallow the medication. Before deciding to open the capsule and mix it with food what will the nurse need to determine?

Answer 28

Determine if the medication is an extended release
Rationale: and extended release medication is formulated for gradual absorption in the body, opening or crushing the medication will adversely affect this action

Question 29

The clients incontinence continues. Use of the condom catheter is resumed until the client develops localized dermatitis. The condom catheter is removed temporarily to promote healing. Although the nursing staff takes the client to the bathroom, every two hours episodes of incontinence occurs occasionally the nurse enters the clients room and finds him crying. What is the best initial response by the nurse to this behavior?

Answer 29

Acknowledge the clients distress
Rationale: acknowledgment of the clients distress is a therapeutic and caring response. That should be the first action implemented by the nurse.

Question 30

When the client is calmed, the nurse assigned the UA to help the client into dry clothing. Several minutes later, the nurse walks down the hall and sees the UAP in the room changing the clients close the nurse enters the room and assesses the situation which aspect of the situation requires the nurses most immediate intervention?

Answer 30

The clients room door is open to the hallway

Rationale: this is disrespectful, demeaning and innovation of the clients privacy. It should be corrected immediately.