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 is caring for a patient who has a urinary diversion (urostomy) after cystectomy (removal of the bladder) to treat bladder cancer. What interventions are indicated for this patient?
Correct Answer: A,C,F
Rationale: Urinary diversion involves the surgical creation of an alternate route for excretion of urine. When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.
Question 2 of 5
A nurse is changing the stoma appliance on a patient's ileal conduit. Which finding requires the nurse to follow up with the provider?
Correct Answer: D
Rationale: The stoma should appear pink to red, shiny, and moist; a dark brown or purple-blue stoma may reflect compromised circulation. The nurse contacts the health care provider immediately. A urostomy is incontinent; urine leakage is expected.
Question 3 of 5
A postoperative patient is having difficulty voiding and reports suprapubic pressure. What action can the nurse take to promote voiding?
Correct Answer: B
Rationale: Factors associated with urinary retention include medications, an enlarged prostate, and vaginal prolapse. Assist the patient to void when the patient first feels the urge. Assessing for residual urine will not promote voiding; rather, it will determine the volume of urine in the bladder. Cold water would cause the patient to tighten their muscles.
Question 4 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 5 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.