ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 59 : Caring for Clients With Disorders of the Bladder and Urethra Questions
Question 1 of 5
A nurse coming from morning report is instructed to use a bladder scanner on a client following a client's attempt at urination. The client is able to void 300 ml. The client denies any pain on urination. The nurse scans 250 ml of remaining urine in the bladder. Which entry is most correct when documenting the intervention?
Correct Answer: C
Rationale: When documenting the results of using a bladder scanner, it is best to note the amount voided and then the residual urine remaining in the bladder. This documentation enables the analysis of the client's ability to empty the bladder.
Question 2 of 5
The nurse is caring for four clients on a urinary medical unit. For which client does the nurse need no further medical interventions?
Correct Answer: B
Rationale: A residual urine in the bladder of 90 mL is not considered urinary retention and would need no further follow-up at this time. Client symptoms of pain need a medical order for medication. An elevated WBC count would need the attention of the physician. The client should be able to void in the morning hours, especially after the night. Further interventions may be necessary.
Question 3 of 5
The best nursing action to remove urine from the bladder is to use a curve-tipped coud?© catheter
Correct Answer: C
Rationale: The best nursing action to remove urine from the bladder is to use a curve-tipped coud?© catheter. The coud?© catheter has a curved tip to slide over the obstruction. Using a large catheter such as a 22 French would meet resistance and traumatize the urethral lining. A straight-tipped catheter also would meet the obstruction and not advance. Crec?º maneuver may eliminate a small amount of urine but does nothing to allow urine flow around the narrowing.
Question 4 of 5
The licensed practical nurse is employed as a charge nurse at a long-term care facility. A resident is ordered a catheterization schedule of every 6 hours due to chronic urinary retention. The LPN reports daily catheterization amounts from the previous day ranging from 450 mL to 800 mL. Which nursing action is most correct?
Correct Answer: C
Rationale: The charge nurse realizes that if the volume of urine obtained via catheterization is more than 400 mL, the client should be catheterized more often. The LPN would call for a change in orders citing the urine volume as the rationale. Leaving the catheter in place is only completed if necessary.
Question 5 of 5
The nurse is assisting in the transport of a client with an indwelling catheter to the diagnostic studies unit. Which action made by the nursing assistant would require instruction?
Correct Answer: B
Rationale: The nurse would instruct the nursing assistant to maintain the drainage bag lower than the genital region to avoid a backflow of urine into the bladder. The nursing assistant is correct to move the catheter and drainage bag with the client to not put tension on the catheter, place the drainage bag on the lower area of the wheelchair, and hold the drainage bag while the client is in the process of moving.