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 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 2 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 3 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 4 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.
Question 5 of 5
A nurse in the emergency room is teaching a patient how to collect a midstream urine specimen. What instructions will the nurse give the patient?
Correct Answer: A,C,D
Rationale: The nurse gives these instructions to collect the midstream/clean-catch urine specimen: Wash your hands with soap and water. Open the collection cup, and place the lid face up; do not touch the inside. Separate the labia and cleanse the urinary opening with soap and water or towelettes included in the kit. Void about 1 oz. (30 mL) into the toilet, then move the collection cup close to the urinary opening and void about 1 oz (no less than 2 teaspoons) into the container. Pass the remainder of the urine into the toilet. Without touching the inside of the lid, close the cup and return it to the nurse.