Module 7 Flashcards
An older adult female client tells the nurse, “Whenever I sneeze or cough, I urinate a little bit. It’s very embarrassing.” The nurse interprets the client’s statement as indicating which type of incontinence?
Stress
A nurse is caring for a client who has just undergone surgery to create an ileal conduit for urinary elimination via a stoma. Which fact about this procedure should the nurse mention to the client?
The client will have to wear an external appliance to collect urine
A nurse drains the bladder of a client by inserting a catheter for 5 minutes. What type of catheter would the nurse use in this instance?
intermittent urethral catheter
While providing care to a client admitted to the health care facility, the client states that she has “a burning sensation when urinating.” After further questioning, the nurse inspects the client’s perineal area. Which sign/symptom would the nurse document as an abnormal finding?
Reddened perineal skin
What is an advantage of using an external condom catheter for a male client who has frequent episodes of urinary incontinence?
It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.
A client with chronic kidney disease reports not being able to urinate for the past 24 hours. A bladder scan shows no urine in the bladder. How does the nurse document this data?
anuria
The nurse is caring for a client who reports burning upon urination, and an ongoing sense of needing to urinate. Which urine characteristics does the nurse anticipate?
cloudy, foul odor
The nurse is caring for a male client who has a urinary obstruction and is not a candidate for surgery. Which intervention will the nurse prepare the client for?
Insertion of a urologic stent
A client in a long-term care facility becomes confused and disoriented at night and is incontinent during these periods of confusion due to the inability to find the commode. During the day, the client does not experience confusion and is continent. What type of incontinence is this client experiencing during the nighttime hours?
functional incontinence
A nurse is caring for a client with a hemodialysis access site. Which action should the nurse take?
Auscultate over the access site with the bell of a stethoscope, listening for a bruit or vibration.
The parent of a 5-year-old child tells the nurse that on two occasions her son has lost control of urination when he had to wait to go to the bathroom at school. What is the appropriate nursing response?
“Let’s review the types of fluids that your child drinks in the morning.”
A woman is reporting bladder urgency. It is most important to assess:
caffeine intake.
The nurse is caring for a client with a prescription for a midstream urine specimen. The nurse would provide which information to the client?
“Void a small amount, stop, and discard it.”
The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately?
Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well.
A client is diagnosed with frequent urinary tract infections. What would be an appropriate question for the nurse to ask the client?
“How frequently do you urinate each day?”
The nurse is caring for a client who has been experiencing difficulty voiding since her vaginal birth. The client voices concern to the nurse. What information should be provided to the client?
The birth can cause perineal swelling
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance?
The client has an enlarged prostate.
Which statement should the nurse convey to the mother of a 3-year-old son who has not achieved urinary continence?
Boys may take longer for daytime continence than girls.
The nurse is reviewing the urinalysis of a client suspected of having a urinary tract infection. The potential diagnosis will be supported by the presence of:
pus
Which condition will have a great impact on the extracellular fluid for water conservation?
Burns
The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include?
“Very little scar tissue will form.”
The nurse is preparing to measure the depth of a client’s tunneled wound. Which implement should the nurse use to measure the depth accurately?
a sterile, flexible applicator moistened with saline
Collection of a wound culture has been ordered for a client whose traumatic hand wound is showing signs of infection. When collecting this laboratory specimen, which action should the nurse take?
Rotate the swab several times over the wound surface to obtain an adequate specimen.
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?
stage III
The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have a shallow skin crater with serous drainage. How will the nurse categorize this pressure injury?
stage III
The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports “it feels numb.” What is the best action by the nurse at this time?
Discontinue the therapy and assess the client.
A client who had a knee replacement asks the nurse, “Why do I need this little bulb coming out of my knee?” What is the appropriate nursing response?
“The drain allows removal of blood and drainage from the surgical wound, which enables healing and protects the skin around the wound.”
A postoperative client is being transferred from the bed to a gurney and states, “I feel like something has just given away.” What should the nurse assess in the client?
Dehiscence of the wound
A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics?
An infant’s skin and mucous membranes are easily injured and at risk for infection
For which client would the application of a hydrocolloid dressing be most appropriate?
A client who has a partial-thickness venous ulcer with moderate drainage
OR
A client who has just undergone a cholecystectomy (gallbladder removal)
A client who has a partial-thickness venous ulcer with moderate drainage
What type of dressing is occlusive or semi-occlusive, limits exchange of oxygen between wound and environment, provides minimal to moderate absorption of drainage, maintains a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing?
hydrocolloid
The nurse observes the presence of intestinal contents protruding from the client’s surgical wound after colon resection. What action will the nurse take?
Apply saline solution–moistened gauze over the protruding area.
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?
Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture?
Keep the swab and the inside of the culture tube sterile prior to collecting the culture.
