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
An older adult client is participating in a bladder retraining program as part of the treatment for urinary incontinence. The nurse advises the client to wear barrier garments such as liners and protective pants. Which suggestion would be most appropriate to help the client maintain skin integrity?
Correct Answer: B
Rationale: Exposing the affected area to air helps maintain skin integrity by reducing moisture, which can lead to skin breakdown in incontinent clients. Avoiding moisture sealant may increase irritation, and scented sprays or perfumes can cause further irritation. Electric room deodorizers do not directly impact skin integrity.
Question 2 of 5
Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?
Correct Answer: B
Rationale: A low-purine diet is used for uric acid stones, the benefits, however, are unknown. Clients with a history of calcium oxalate stone formation need a diet that is adequate in calcium and low in oxalate. Only clients who have type II absorptive hypercalciumâ??approximately half of the clientsâ??need to limit calcium intake. Usually, clients are told to increase their fluid intake significantly, consume a moderate protein intake, and limit sodium. Avoiding excessive protein intake is associated with lower urinary oxalate and lower uric acid levels. Reducing sodium intake can lower urinary calcium levels.
Question 3 of 5
The nurse is caring for a client for whom an ileal conduit is created after a radical cystectomy. Which instructions would the nurse expect to include in the client's plan of care?
Correct Answer: A
Rationale: An ileal conduit involves care of a urinary stoma, much like that of a fecal stoma, including the application of an ostomy pouch, skin protection, and stoma care. Intermitient catheterizations and irrigations are appropriate for a continent urinary diverse such as a Kock or Indiana pouch. Exercises to promote sphincter control are appropriate for an ureterosigmoidoscopy.
Question 4 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 5 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.