Exam 2 CH47

1
Front:

1. The nurse is assessing a client's urinary elimination. Which factor should the nurse keep in
   mind as influencing this elimination?

1) Age
2) Body image
3) Knowledge
4) Socioeconomic status

Correct Answer: 1
Explanation: Development factors such as how old the client is influence urinary elimination.

2
Front:
2) The nurse realizes that which client is at risk for difficulty in urinary elimination?

1. A client who had bladder cancer and now has a newly created ileal conduit

2. A 25-year-old female client with low self-esteem

3. An 80-year-old male reporting frequent urination at night

4. The client with hypertension who takes a diuretic every day for blood pressure

Correct Answer: 3
Explanation: The client who is 80 years old with frequent urination at night is having problems
with his prostate. Older male adults experience urinary retention due to prostate enlargement
causing an alteration in urinary elimination.

3
Front:
3) A client tells the nurse about the need to get up several times throughout the night to void. The
nurse suspects the client is experiencing nocturia due to which factor?

1. Decrease in bladder tone
2. Decrease in blood supply
3. Decrease in number of nephrons
4. Decrease in cardiac output

Correct Answer: 1
Explanation: Nocturia is voiding frequently at night. An increased intake of fluid causes some
increase in the frequency of voiding. Conditions such as urinary tract infection, stress, and
pregnancy can cause frequent voiding of small quantities of urine. Total fluid intake and output
may be normal.

4
Front:
4) Which intervention would the nurse plan to help a client prevent a urinary tract infection?

1. Encourage the use of bubble baths.
2. Have the client increase sugar in the diet.
3. Instruct the client to empty the bladder completely.
4. Wipe from back to front.

Correct Answer: 3
Explanation: Completely emptying the bladder prevents stasis of urine, which would contribute
to a urinary tract infection.

5
Front:
5) The nurse should incorporate which instructions into the teaching plan for a client with a
urinary diversion?

1. Change the appliance several times a day.
2. Increase fluid intake.
3. Notify the physician if the stoma is deep pink and shiny.
4. Strands of blood may appear in the urine.

Correct Answer: 2
Explanation: Increasing the fluid intake helps to flush out sediment and mucus and prevents
clogging of the stoma.

6
Front:
6) Which nursing intervention is appropriate when caring for a client with an indwelling urinary
catheter?

1. Don sterile gloves.
2. Gently retract the labia majora away from the urinary meatus.
3. Observe urine in the drainage bag.
4. Retape the catheter to the thigh.

Correct Answer: 4
Explanation: Retaping the catheter to the thigh after care is given prevents trauma and pain from
tension and pulling.

7
Front:
7) Which nursing diagnosis would be appropriate for a client who has a retention catheter if the
drainage bag is found lying on the floor?

1. Risk for Impaired Skin Integrity related to catheter placement
2. Risk for Infection related to improper handling
3. Self-Care Deficit related to presence of a retention catheter
4. Risk for Incontinence related to an obstruction

Correct Answer: 2
Explanation: The floor is the dirtiest place, so the drainage device should never be placed on the
floor.

8
Front:
8) The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary
Incontinence. Which outcome would be related to sphincter incompetence?

1. The client will empty the bladder with each void.
2. The client will improve incontinence within 1 month.
3. The client will perform eight squeezes three times a day.
4. The client will stop the flow of urine when voiding.

Correct Answer: 3
Explanation: Performing eight squeezes three times a day is the goal when teaching a client
Kegel exercises, which are used for stress and urge incontinence.

9
Front:
9) Which goal should the nurse identify as appropriate for a client with the nursing diagnosis
Urinary Pattern Alteration related to an enlarged prostate?

1. The client will avoid bladder distention.
2. The client will maintain fluid imbalance.
3. The client will remain free of skin breakdown.
4. The client will voice increased discomfort.

Correct Answer: 1
Explanation: Avoiding bladder distention will help eliminate stasis of urine in the bladder,
which contributes to urinary tract infections, a possible complication of urine flow being
obstructed from an enlarged prostate.

10
Front:
10) A client is diagnosed with a urinary disorder. Which physical assessment techniques should
the nurse use in assessing this client's urinary system?

1. Auscultation and inspection
2. Inspection and percussion
3. Observation and auscultation
4. Palpation and percussion

Correct Answer: 4
Explanation: Palpation and percussion are used to assess the bladder.

11
Front:
11) A client has been admitted with incontinence. What should the nurse expect to assess in this
client?

1. Client is wearing cotton undergarments.
2. Leakage of urine occurs when client laughs.
3. Leakage of urine occurs when talking with the client.
4. The skin of the client is clear without discoloration.

Correct Answer: 2
Explanation: Incontinence involves a small leakage of urine when a client laughs.

12
Front:
12) A client is rushed to the emergency department with what the physicians suspect to be
necrosis of the urinary diversion stoma. What evidence presented by the client leads to this
conclusion?

1. Black with sloughing
2. Moist stoma
3. Pink and shiny
4. Slight bleeding from stoma

Correct Answer: 1
Explanation: Black color to the stoma and sloughing are signs of necrosis of the stoma.

13
Front:
13) A client's results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 10-15,
glucose negative, specific gravity 1.012, and protein negative. How should the nurse interpret the
results?

1. Dehydration
2. Diabetic ketoacidosis
3. Trauma
4. Urinary tract infection

Correct Answer: 4
Explanation: The pH, glucose, specific gravity, and protein are all within normal limits. Urine is
usually clear to slightly cloudy, and WBC count can be from 0 to 4. Therefore, the gross
cloudiness and WBC count of 10-15 are not normal, indicating a urinary tract infection.

14
Front:
14) A client's urinalysis is reported as being normal. What were the client's results?

1. Blood present and no ketones
2. Dark amber color and output less than 500 cc in 24 hours
3. pH 6 and no glucose present
4. Specific gravity 1.035 and faint aromatic odor

Correct Answer: 3
Explanation: Normal pH is 4.5 to 8, so a pH of 6 and no glucose present are two normal
characteristics of urine.

15
Front:
15) A client is prescribed propranolol (Inderal). What should the nurse instruct the client about
this medication?

1. The medication should be discontinued abruptly.
2. Notify the physician if you experience urinary retention.
3. Take a laxative every day.
4. Take the medication on an empty stomach.

Correct Answer: 2
Explanation: A beta-adrenergic blocker such as propranolol can cause urinary retention;
therefore, it would be of the utmost importance to notify the physician.

16
Front:
16) A client is having issues with urinary elimination. What should the nurse instruct this client
to help with this problem?

1. Don't interrupt your day by going to the bathroom; wait until you're at a good stopping place.
2. Drink 8-10 glasses of water daily.
3. Urine color changes are not important.
4. Wash with soap and water every other day.

Correct Answer: 2
Explanation: Drinking 8-10 glasses of water daily will encourage the need for bladder emptying,
keeping the system flushed.

17
Front:
17) A client recovering from a transurethral resection of the prostate with a three-way indwelling
catheter expresses the need to urinate. Which action should the nurse take to help this client?

1. Deflate and then reinflate the balloon.
2. Irrigate the catheter.
3. Reposition the catheter.
4. Retape the catheter to the abdomen.

Correct Answer: 2
Explanation: Blood clots give the client the sensation to urinate when they obstruct the urine
outflow; therefore, irrigation will have to remedy the problem.

18
Front:
18) The nurse is caring for a client with a urinary diversion. For which type of diversion should
the nurse plan care for this client?

1. Incontinent urinary diversion
2. The kock pouch
3. Neobladder
4. Nephrostomy

Correct Answer: 1
Explanation: This is an incontinent urinary diversion (ileal conduit).

19
Front:
19) A client has a spinal cord injury at the cervical spine area. The nurse realizes that this injury
will affect which aspect of urinary elimination in the client?

1. Elimination of urine from the bladder
2. Ability of the kidneys to absorb solutes
3. Ureteral function
4. Urethra function

Correct Answer: 1
Explanation: The bladder contains the detrusor muscle, which is responsible for expulsion of
urine from the bladder. If the client has a cervical spine injury, muscle function will be affected
below the level of the injury, resulting in an impaired ability to eliminate urine from the bladder.

20
Front:
20) A client is complaining of pain with urination. The nurse realizes that the client needs to be
assessed for which health problems? (Select all that apply.)

1. Urethral stricture
2. Renal failure
3. Urethral injury
4. Bladder injury
5. Urinary infection

Correct Answer: 1, 3, 4, 5

21
Front:
21) A client needs a test to determine the amount of residual urine. The nurse realizes that this
assessment is used for which reason(s)? (Select all that apply.)

1. Evaluate the glomerular filtration rate
2. Determine the extent of renal failure
3. Determine the amount of retained urine after voiding
4. Determine the need for medications
5. Evaluate fluid volume status

Correct Answer: 3, 4

22
Front:
22) A client's urine pH is 8.0. What further assessments would be indicated for this client?
(Select all that apply.)

1. Intake of fruits and vegetables
2. Intake of cranberries
3. Intake of high-protein foods
4. Symptoms of diarrhea
5. Symptoms of a urinary tract infection

Correct Answer: 1, 5
Explanation: Alkaline urine might indicate a diet high in fruits and vegetables.
Alkaline urine might indicate a urinary tract infection.

23
Front:
23) The nurse is instructing a client on ways to manage stress urinary incontinence. What should
be included in this client's teaching? (Select all that apply.)

1. Limit intake of caffeine.
2. Limit intake of alcohol.
3. Increase intake of citrus juices.
4. Limit evening fluid intake.
5. Increase intake of beverages with artificial sweeteners.

Correct Answer: 1, 2, 4

24
Front:
24) The nurse is concerned that a client is at risk for the development of urinary tract infections.
What did the nurse assess to come to this conclusion?

1. The client is wearing tight clothing.
2. The client is employed as a computer operator.
3. The client drinks 8 to 10 8-ounce glasses of water and low-calorie beverages each day.
4. The client exercises for 30-60 minutes most days of the week.

Correct Answer: 1
Explanation: Tight-fitting pants or other clothing can cause irritation to the urethra and prevent
ventilation of the perineal area, leading to an infection.

25
Front:
25) The nurse is concerned that an older client with an indwelling urinary catheter is developing
a urinary tract infection. What assessment finding caused this concern?

1. Elevated blood pressure
2. Elevated heart rate
3. Confusion
4. Leg pain

Correct Answer: 3
Explanation: In the older client, confusion can be an early sign of urinary tract infection.

26
Front:
26) The nurse is applying an external urinary device to a client. Before attaching the device to
the drainage bag, what should the nurse do?

1. Perform hand hygiene.
2. Document the client's tolerance of the procedure.
3. Instruct the client about the drainage system.
4. Ensure that the condom is not twisted.

Correct Answer: 4
Explanation: The nurse should make sure that the tip of the penis is not touching the condom
and that the condom is not twisted because a twisted condom could obstruct the flow of urine.

27
Front:
27) The nurse is performing urinary catheterization for a client. After using the nondominant
hand to separate the client's labia for cleansing, in which way should the nurse treat this hand?

1. Sterile
2. Contaminated
3. Able to evaluate the effectiveness of the catheter balloon
4. Clean

Correct Answer: 2
Explanation: When performing urinary catheterization, the nondominant hand is considered
contaminated once it touches the client's skin.

28
Front:
28) The nurse wants to delegate the application of a condom catheter to assistive personnel (AP).
What must the nurse assess prior to delegating this task?

1. Assess whether the client has unique needs.
2. Measure the client's intake.
3. Assist the client out of bed to a chair.
4. Assess changes in the client's mobility status.

Correct Answer: 1
Explanation: Applying a condom catheter may be delegated to AP. However, the nurse must
determine whether the specific client has unique needs, such as impaired circulation or latex
allergy, that would require special training of the AP in the use of the condom catheter.

29
Front:
29) The nurse is determining tasks to assign to AP. Which task should the nurse question before
assigning to this level of healthcare provider?

1. Measuring intake and output
2. Assessing vital signs for clients who are clinically stable
3. Performing complete morning care for a client recovering from a stroke
4. Inserting a urinary catheter into a client

Correct Answer: 4
Explanation: Due to the need for sterile technique and detailed knowledge of anatomy, insertion
of a urinary catheter is not delegated to AP.

30
Front:
30) The nurse is documenting the insertion of an indwelling urinary catheter for a client. What
should be included in this documentation? (Select all that apply.)

1. Catheter size
2. Location of the drainage bag
3. Amount of urine that drained after insertion
4. Name of the physician who prescribed the insertion of the catheter
5. Client tolerance of the procedure

Correct Answer: 1, 3, 5

31
Front:
31) Assistive personnel (AP) has applied a condom catheter to a client. The nurse should
document what information about this procedure? (Select all that apply.)

1. Number of mL of fluid used to inflate the balloon
2. Location of the drainage bag
3. Name of the AP who applied the device
4. Time and date that the condom catheter was applied
5. Integrity of the penis

Correct Answer: 4, 5
Explanation: The nurse should document the application of the condom, including the time.
The nurse should document any pertinent observations, such as the integrity of the penis.

32
Front:
32) The nurse has completed closed irrigation of a client's retention catheter. What specific
information should the nurse document about this procedure?

1. Number of mL of solution used to inflate the balloon of the catheter
2. Abnormal drainage, such as blood clots, pus, or mucous shreds
3. Location of the draining bag
4. Technique used to conduct the irrigation

Correct Answer: 2
Explanation: The nurse should note any abnormal constituents, such as blood clots, pus, or
mucous shreds.

33
Front:
33) A client with an indwelling urinary catheter is prescribed to receive sterile normal saline
bladder irrigation at 100 mL/hr. After an 8-hour shift the nurse measures the client's output as
being 1425 mL. What is the client's urine output for the 8-hour shift? Calculate to the nearest
whole number.

Correct Answer: 625 mL
Explanation: The client is to receive 800 mL of bladder irrigant for the 8-hour shift. The nurse
needs to subtract the bladder irrigant total from the total output, or 1425-800=625 mL. This is the
client's urine output for the 8-hour shift.

34
Front:
34) An older female client with a history of urinary tract infections has an indwelling urinary
catheter. What should the nurse do to reduce this client's risk of developing an infection because
of the catheter? (Select all that apply.)

1. Maintain a sterile closed drainage system.
2. Clean the peri-urethral area with antiseptics.
3. Ensure the catheter and tubing are not kinked.
4. Wash hands before manipulating the catheter.
5. Keep the collection bag below the level of the bladder.

Correct Answer: 1, 3, 4, 5

35
Front:
35) The nurse is explaining the process of urine formation. Which should the nurse explain
occurs with urine after it is formed in the kidneys?

1. Enters the bladder
2. Filters metabolic wastes
3. Moves through the urethra
4. Moves into the renal pelvis

Correct Answer: 4
Explanation: Once urine is formed it moves into the renal pelvis. It enters the bladder through
the ureters. It moves through the urethra upon urination. The kidneys filter metabolic wastes.

36
Front:
36) During an assessment a client states the urgent need to void urine. Which should the nurse
identify as the reason for the client to use the bathroom?

1. Burning of the urethra
2. Relaxation of the trigone
3. Activation of stretch receptors
4. Contraction of bladder ligaments

Correct Answer: 3
Explanation: Urine collects in the bladder until pressure stimulates special sensory nerve
endings in the bladder wall called stretch receptors. Urethral burning indicates an infection. The
trigone is an area of the bladder where the ureters enter. Bladder ligaments do not contract when
the bladder is full.

37
Front:
37) The nurse needs to insert an indwelling urinary catheter into a client. For which reason
should the nurse ask assistive personnel to help with the procedure?

1. Distracts the client
2. Improves visualization
3. Evaluates the nurse's skill level
4. Ensures sterile technique is followed

Correct Answer: 2
Explanation: Having assistance with the insertion of an indwelling urinary catheter improves
visualization. Assistance is not used to distract the client, evaluate the nurse's skill level, or
ensure that sterile technique is f