Meeting Basic Physiologic Needs
Review Questions
Question 1: Incontinent Patient - Priority Action
The priority action for a nurse caring for an incontinent patient is to gather data to find the cause of the incontinence.
- Why? Determining the underlying cause is crucial for developing an effective management plan.
- Incorrect Options:
- Helping the patient void every 2 hours: This is a potential intervention, but addressing the cause is more important.
- Decreasing fluid intake: This can lead to dehydration and might not solve the incontinence issue.
- Encouraging expression of embarrassment: Addressing emotional needs is important, but the physical problem needs to be addressed first.
Question 2: Midstream Urine Specimen - Greatest Concern
The urine characteristic of greatest concern in a midstream urine specimen is dark brown color.
- Why? Dark brown urine can indicate serious conditions like kidney disease, liver problems, or severe dehydration.
- Incorrect Options:
- Slight ammonia smell: Normal due to urea breakdown.
- Dilute urine: Can indicate overhydration, diabetes insipidus, or kidney problems, but not as alarming as dark brown.
- Slightly cloudy urine: Could be due to phosphates, epithelial cells, or mild infection, but less concerning than dark brown.
Question 3: Male Patient with Urinary Retention - Before Catheterization
Before catheterization, the nurse should perform a bladder scan to determine the amount of urine retained.
- Why? A bladder scan provides a non-invasive way to assess the amount of urine in the bladder, helping to confirm urinary retention and guide the decision to catheterize.
- Incorrect Options:
- Condom catheter: Not appropriate for retention.
- Waiting 2 hours: Delays intervention and can cause discomfort.
- Drinking water: Will worsen retention before catheterization.
Question 4: Catheterizing a Male Patient - Resistance Met
If resistance is met when catheterizing a male patient, the nurse should ask the patient to take a deep breath and slowly exhale as the catheter is inserted.
- Why? This technique can help relax the sphincter muscles, allowing easier catheter passage.
- Incorrect Options:
- Applying more pressure: This can cause trauma to the urethra.
- Using a Coudé catheter: May be necessary if simple measures fail but not the first action.
- Discontinuing: Premature; try relaxation techniques first.
Question 5: Bladder Irrigation - Clamping the Tubing
The best rationale for clamping the tubing during bladder irrigation to instill medication is to prevent the solution from going directly into the bag.
- Why? Clamping ensures the medication remains in the bladder for the intended duration to exert its therapeutic effect.
- Incorrect Options:
- Standard procedure: While it is standard, the reason matters.
- Maintaining sterility: Important, but not the primary reason for clamping.
- Preventing urine reflux: A secondary benefit, but not the main reason.
Question 6: Clean Catch Method - Patient Understanding
The statement that indicates an understanding of how to perform the clean catch method for a urine specimen is: "I should clean myself first, pee a little into the toilet, and then pee into the cup."
- Why? This statement correctly describes the process of cleaning the perineal area, initiating urination to flush the urethra, and then collecting the midstream urine in the cup.
- Incorrect Options:
- Peeing and then cleaning: This would contaminate the sample.
- Filling the cup completely: Only a small amount is needed.
- Keeping the kit sterile: While important, this isn't the core instruction.
Question 7: Post-Prostatectomy - Increasingly Red Urine
If a patient who had a resection of the prostate gland yesterday and has a three-way catheter for continuous irrigation has draining urine that is increasingly red, the nurse needs to increase the rate of flow of the irrigation solution.
- Why? Increasing the irrigation rate helps to flush out the blood and prevent clot formation in the bladder.
- Incorrect Options:
- Notifying the surgeon: Necessary if bleeding is excessive or doesn't respond to increased irrigation.
- Increasing fluid intake: Hydration is important, but irrigation directly addresses the bleeding.
- Emptying the drainage bag: Important, but not the immediate solution.
Question 8: 24-Hour Urine Specimen - Discarded Urine
If the nursing assistant discards some of the urine that should have been saved for a 24-hour urine specimen, the most appropriate nursing action is to notify the charge nurse and restart the test.
- Why? The accuracy of the 24-hour urine test is compromised if any urine is discarded, necessitating a restart.
- Incorrect Options:
- Reprimanding the assistant: Address later; focus on patient needs first.
- Extending the collection: This won't correct the missed sample.
- Continuing the collection: The results would be inaccurate.
Question 9: Urinary Catheter Removal - Correct Order of Actions
The correct order is:
- Check provider order
- Perform hand hygiene and don gloves
- Position patient in high-Fowler position
- Place towel under the catheter; attach syringe to the balloon port of the catheter
- Withdraw water from the balloon until resistance is met
- Gently remove catheter
- Inspect catheter to make sure it is intact
- Remove gloves, perform hand hygiene, and make patient comfortable
- Measure and record urinary output
- Document procedure