ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 38 Questions
Question 1 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 2 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 3 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 4 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 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.