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The nurse collects data about a patient regarding risk for stress incontinence. Which is a major contributing factor for this condition?
A. Spinal Cord dysfunction
B. Cognitive impairment
C. Decreased bladder capacity.
D. Weak pelvic muscles
D. Weak pelvic muscles
Rationale: stress incontinence is an immediate involuntary loss of urine during an increase in intra-abdominal pressure. It is related to weak or degenerated pelvic muscles and structural supports.
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What should the nurse monitor to best assess a patient's renal perfusion?
Urinary output every hour.
Rationale: Adequate renal perfusion and kidney function are reflected by an hourly urine output of 30 to 50 ml of urine.
A patient has a urinary retention catheter. Which is most important when the nurse cares for this patient?
A. cleansing the urinary meatus with betadine daily
B. increasing fluid intake to 3000 ml per day
C. wearing sterile gloves when accessing the specimen port
D. Ensuring that the catheter remains connected to the collection bag
D. Ensuring the catheter remains connected to the collection bag
Rationale: maintaining the connection of the catheter to the drainage bag prevents the introduction of microorganisms that can cause infection. A urinary retention catheter is a closed system that should remain closed.
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What is dysuria?
Painful or difficult urination
The nurse is assessing a patient's urinary status. Which adaption indicates urinary retention?
Bladder fullness in the absence of voiding.
In urinary retention, urine accumulates in and distends the bladder, resulting in bladder fullness, absence of voiding, and suprapubic distention.
The nurse should be most concerned about which problem when patients have bowel and bladder incontinence?
A.lowered level of consiousness
B.decreased fluid volume
C. impaired skin integrity
D. imbalanced nutrition
Impaired skin integrity
When the nurse documents that the patient has polyuria, the nurse is communicating that the patient is:
Excreting excessive amounts of urine.
Polyuria is an excessive output of urine. This is associated with problems such as diabetes mellitus, diabetes insipidus, diuresis phase after a burn injury, and reduced antidiuretic hormone.
A patient is experiencing bladder irritability. Which fluid should the nurse teach the patient to include in the diet?
Cranberries have no constituents that irritate the bladder. In addition, it produces a more acidic environment that is less conducive to the growth of microorganisms and prevents bacteria from adhering to the mucous membranes of the urinary tract, promoting their excretion.
Wha adpation identified by the nurse most commonly is associated with excessive production of the hormone ADH?
Antidiuretic hormone increases the reabsorption of water by the kidne tubules, decreasing the amount of urine formed. Oliguria is diminished urinary output relative to intake. (less than 400 ml in 24 hours)
The nurse has identified that the patient has overflow incontinence. The nurse understands that the major contributing factor is:
B. mobility deficits
C. prostate enlargement
An enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urtheral sphincter temporarily opens to allow a small volume (25 to 60 ml) or urine to escape (overflow incontinence)
The patients urine is cloudy, amber, and has an unpleasant odor. The nurse makes the inference that the patient has:
Urinary tract infection
Urine appears concentrated (amber) and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria).
The nurse must collect a urine specimen for culture adn sensitivity via a straight catheter. The nurse should:
A. use a sterile specimen container
B. collect urine from the catheter port
C. inflate the balloon with ten ml of sterile water
D. have the paitent void before collecting the specimen
Use a sterile specimen container
A culture attempts to identify the microorganisms present in the urine, and a sensitivity identifies the antibiotics that are effective against the isolated microorganisms. A sterile specimen container is used to prevent contamination of the specimen by microorganisms outside the body (exogenous).
The nurse is caring for a patient with a condom catheter. Which nursing action is most important?
A. providing perineal care every shift
B. avoiding kinks in the collection tubing
C. ensuring that the velcro strap is snug, not tight
D. retracting the foreskin before the cather is applied
Ensuring that the velcro strap is snug, not tight
The anchoring device (velcro, elastic, self adhesive, inflatable ring) must be snug enough to prevent the condom from falling off, but not so tight that it interferes with blood circulation to the penis.
The nurse is caring for a patient on bed rest who has a urinary retention catheter. The nurse should:
A. irrigate the tubing to ensure patency
B. label the tubing with the collection tubing
C. ensure the tubing is positioned over the leg
D. hang the collection bag on the side rail of the bed
Ensure the tubing is positioned over the leg
Rationale: this prevents pressure of the leg on the drainage tube that can interrupt the flow of urine out of the bladder
Which should the nurse teach the patient to avoid to prevent urinary diuresis?
Drinks with caffeine promote diuresis, which is secretion and excretion of large amounts of urine
The nurse identifies that the constituent found in urine that indicates an abnormality is:
The presence of protein in the urine indicates that the glomeruli have become too permeable, which occurs with kidney disease. Most plasma proteins are too large to move out of the glomeruli, and the small proteins that enter the filtrate are reabsorbed by pinocytosis.
The nurse is caring for a group of patients with a variety of urinary problems. The patient adaptation identified by the nurse that causes the most concern is:
The inability to produce urine is a life-threatening situation. If the cause is not corrected, the patient will need dialysis to correct fluid and electroylte imbalances and rid the body of the waste products of metabolism
Which problem identified by the nurse is most associated with urinary incontinence?
A. chronic pain
B. reduced fluid intake
C. disturbed self esteem
D. insufficient knowledge
Disturbed self esteem
Disturbed self esteem is the state in which an indv. expereiences, or is at risk for experiencing, negative self evaluation about self of capabilities. incontinence may be viewed by the patient as regressing to child like behavior and has a negative impact on feelings about self.
Which characteristic is common to both reflex incontinence and total incontinence?
A. urination following an increase in intra-abdominal pressure
B. loss of urine without awareness of bladder fullness
C. retention of urine with overflow incontinence
D. strong, sudden desire to void
Loss of urine without awareness of bladder fullness
Rationale: involuntary voiding, and lack of awaress of bladder distention, are related to both reflex incontinence and total incontinence. Reflex incontinence is the predictable, involuntary loss of urine with no sensation of urgency, of the need to void or bladder fullness. Total incontinence is the continuous unpredictable loss of urine without distention or awareness of bladder fullness.
Which adaption can the nurse expect when a postoperative patient experiences stress associated with surgery?
A. decreased urinary output
B. low specific gravity
C. reflex incontinence
D. urinary hesitancy
Decreased urinary output
Rationale: during the general adaptation syndrome, the posterior pituitary secretes antidiuretic hormone that promotes water reabsorption in the kidney tubules. Also, the anterior pituitary secretes ACTH that stimulates the adrenal cortex to secrete aldosterone, which reabsorbs sodium and thus water.
Decreased specific gravity of urine may indicate:
- Excessive fluid intake
- Diabetes insipidus
- nephrogenic Renal failure (that is, loss of ability to reabsorb water)
A patient tells the nurse, "i have to urinate as soon as i get the urge to go." which is a contributing factor to urinary urgency?
B. full bladder
D. urinary tract infection
Rationale: feeling the need to void immediately (urgency) occurs most often when the urinary bladder is irritated. In the adult, the bladder usually holds 600 ml of urine, although the desire to urinate can be sensed when it contains as little as 150 to 200 ml.
A patient has a history of UTI's. THe nurse should encourage the patient to drink 8 ounces of cranberry juice daily b/c it:
A. dilutes bacterial growth
B. promotes an acidic urine
C. prevents urinary retention
D. stimulates hypoactive detrusor muscles
- Promotes an acidic urine
- Rationale: foods that promote an acid urine (cranberries, prunes, plums, eggs, meat, and whole grain breads) create an environment that is not conducive to the growth of bacteria in urine. Microorganisms grow more readily in an alkaline urine.
When planning nursing care, which factor in the patients history places the patient at greatest risk for stress incontinence?
A. lumbar spinal cord injury
B. urinary obstruction
C. six vaginal births
- Six vaginal births
- Rationale: stress incontinence is an immediate involuntary loss of urine during increase in intra-abdominal pressure. it is associated with weak pelvic muscles and structural supports resulting from multiple preganancies, age related degenerative changes, and overdistention between voiding.
When the nurse assesses a patient, which adptation support the presence of urinary retention? Chose all that apply:
C. bladder contractions
D. suprapubic distention
E. frequent small voidings
Nocturia, suprapubic distention, frequent small voidings
Raitonale: Nocturia- Excessive urination at night is called nocturia. A person with urinary retention will have small, frequent voidings or dribbling rather than a complete discharge of urine from the bladder. Suprapubic distention- the bladder lies in the pelvic cavity behind the symphysis pubis. When is fills with urine (600 ml), it extends above the symphsis pubis, and when greatly distended (2000-3000 ml) it can reach the umbilicus.
Where should the nurse clamp the catheter drainage system in order to obtain a urine specimen for a urine culture and sensitivity?
The tubing from the collection bag that is attached to the catheter inserted into the bladder should be clamped 2-3 inches below the collection port. This location allows urine to collect above the port.
Percussion of the _________________________ that results in pain or discomfort could indicate the presence of an inflammatory process in the kidney.
_________________________ is the application of gentle, manual pressure over the bladder to promote bladder emptying.
A/an _________________________ is a type of urinary diversion that involves implanting the ureters into a small segment of the small intestine, which is then brought to the abdominal wall where a stoma is created.
f a child is experiencing involuntary urination after the age of 5 or 6, he may have a condition known as _________________________.
T or F: The nurse should call the physician immediately if a patient’s urostomy stoma is red in color.
False, this is a normal finding.
T or F: It is important for the nurse to assess the results of the serum blood urea nitrogen and serum creatinine lab tests for the patient receiving certain chemotherapy agents.
True, Chemotherapy agents can also be nephrotoxic.
Mrs. Sanchez is awaiting surgery for a right hip fracture. The physician suspects that Mrs. Sanchez has a urinary tract infection. The nurse anticipates that the physician will order which of the following?
A. Freshly voided urine specimen in the morning
B. Clean-catch specimen
C. Sterile urine specimen
D. 24-Hour urine collection
Sterile urine specimen
Rationale:For most patients, a clean-catch specimen would be ordered. However, because Mrs. Sanchez would need to use a “fracture pan,” it is very likely that the specimen would be contaminated during collection. As a result, a straight catheterization will be needed.