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 patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output?
Correct Answer: A
Rationale: Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.
Question 2 of 5
The health care provider has ordered an indwelling catheter to be inserted to relieve urinary retention in a male patient with prostate enlargement. What consideration will the nurse keep in mind when performing this procedure?
Correct Answer: A
Rationale: Because of the length of the male urethra and need to insert the catheter 6 to 8 inches, it is more prone to injury. The nurse inserts the catheter for a female patient 2 to 3 inches. This procedure requires surgical asepsis to prevent introducing bacteria into the urinary tract. The presence of an indwelling catheter places the patient at risk for a UTI.
Question 3 of 5
A nurse is caring for a patient with an enlarged prostate who has had an indwelling catheter for several weeks. A prescription for continuous bladder irrigation (CBI) is written after the patient developed hematuria post cystoscopy. The nurse teaches the patient the purpose of CBI is to prevent what situation?
Correct Answer: C
Rationale: Post procedure continuous bladder irrigation, in the presence of hematuria, prevents stasis of blood and clot formation potentially obstructing urine output. In the absence of hematuria, clots or debris, natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction.
Question 4 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 5 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.