ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 38 : Urinary Elimination Questions
Question 1 of 5
A nurse caring for a patient who just began hemodialysis assesses the patient's AV fistula. Nursing documentation includes: '5/10/25 0930 AV fistula in the right forearm negative for thrill and bruit. Patient denies pain and tenderness.' Which finding is essential for the nurse report to the health care provider?
Correct Answer: A
Rationale: The nurse palpates and auscultates over the access site, feeling for a thrill or vibration and listening for the bruit or swishing sound. Presence of the thrill and bruit are normal findings, indicating patency of the access. Decreased or absent thrill and/or bruit indicates that there is an issue with the patency of the access, which could be a result of narrowing or clotting of the access, resulting in poor blood flow. No report of pain, redness, or swelling is a normal finding. A trace of edema is not a priority.
Question 2 of 5
A nurse is caring for an alert, ambulatory, older adult with urinary frequency who has difficulty making it to the bathroom in time. Which nursing intervention is most appropriate to include in the care plan for this patient?
Correct Answer: C
Rationale: Pelvic floor exercises (Kegel exercises) may help a patient regain control of the micturition. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. Due to risk for infection, an indwelling catheter is the last choice of treatment.
Question 3 of 5
A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic) for a UTI. The patient states, 'My urine was bright orange-red today; I think I'm bleeding. Something is terribly wrong.' How will the nurse best respond?
Correct Answer: A
Rationale: Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine; the nurse educates the patient to expect this change.
Question 4 of 5
A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What nursing interventions are appropriate to include when caring for this patient?
Correct Answer: A,E,F
Rationale: Maintaining free urinary drainage is a nursing priority. Institute measures to prevent the tubing from becoming kinked and urine from backing up in the tubing. The catheter should be allowed to drain freely through tubing that is not kinked. Nursing care of a patient with a urinary sheath includes skin care to prevent excoriation. Remove the condom daily and wash the penis with soap and water, and dry it carefully. Care must be taken to fasten the sheath securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. The tip of the tubing should extend 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area. Confining a patient to bedrest increases the risk for hazards of immobility.
Question 5 of 5
A nurse receives a prescription to catheterize a patient following surgery. What nursing action reflects correct technique?
Correct Answer: B
Rationale: The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient. The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16 Fr gauge commonly used. A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise.