Chapter 29: Promoting Urinary Elimination My Nursing Test Banks

Chapter 29: Promoting Urinary Elimination

Test Bank

MULTIPLE CHOICE

1. The nurse caring for a severely dehydrated patient who has a Foley catheter in place assesses the patient to confirm adequate urine perfusion by the urine output of _____ mL.

a.

15

b.

30

c.

45

d.

60

ANS: B

There should be an average hourly urine output of 30 mL.

DIF: Cognitive Level: Knowledge REF: p. 537 OBJ: Clinical Practice #1

TOP: Urinary Output KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

2. To help reduce a patients risk of recurrent cystitis, the nurse teaches the patient to:

a.

eat citrus fruits to alkalinize the urine.

b.

always wipe the perineal area from back to front.

c.

take long, warm bubble baths.

d.

wear cotton underwear and avoid nylon or constrictive clothing.

ANS: D

The patient should wear cotton underwear and avoid nylon and constrictive clothing that worsens perineal moisture.

DIF: Cognitive Level: Comprehension REF: p. 538, Health Promotion

OBJ: Clinical Practice #1 TOP: Prevention of Urinary Infections

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and detection of disease

3. The nurse is aware that in the elderly, a urinary infection may cause the patient to:

a.

run an exceptionally high temperature.

b.

have foul urine and diarrhea.

c.

become disoriented and confused.

d.

become irritable.

ANS: C

Urinary infections in the elderly patient may not be manifested by fever. There are subtle changes in mental status.

DIF: Cognitive Level: Comprehension REF: p. 538, Elder Care

OBJ: Clinical Practice #1 TOP: Urinary Infection in the Elderly

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

4. To prevent changes in the chemical characteristics of urine, a nurse sends a sample of fresh urine to the laboratory for urinalysis within at least _____ minutes.

a.

1 to 2

b.

3 to 5

c.

5 to 10

d.

20 to 30

ANS: C

Urine that stands for 15 minutes or longer changes characteristics, and the urinalysis will no longer be accurate.

DIF: Cognitive Level: Comprehension REF: p. 539 OBJ: Clinical Practice #1

TOP: Urinalysis KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

5. A patient has been ordered to have a 24-hour urine collection as part of a diagnostic workup. The action taken to perform this procedure correctly is to:

a.

continue the collection if the patient accidentally voids directly into the toilet.

b.

obtain a container and put it in a warm water bath in the bathroom.

c.

have the patient void at the beginning of the collection and throw it away.

d.

have the patient void for the last time a few hours before the collection ends.

ANS: C

The patients bladder should be empty when the test begins; for this reason, the urine obtained at the start time is discarded and the urine collected should be stored on ice during the 24-hour period.

DIF: Cognitive Level: Application REF: p. 540 OBJ: Clinical Practice #1

TOP: 24-Hour Urine Collection KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

6. A nurse would modify the urine collection technique when a urine sample is needed from an infant by:

a.

placing the infant on a bedpan after removing the diaper.

b.

removing the diaper after the infant voids and send the diaper to the laboratory.

c.

attaching a bag with adhesive backing to the skin surrounding the genitals.

d.

applying a very small condom catheter.

ANS: C

A urine collection bag is attached to the skin by an adhesive backing and is placed so that it surrounds the genitals; when sufficient urine is collected, the bag is removed and urine is put into a specimen cup to send to the laboratory.

DIF: Cognitive Level: Application REF: p. 540 OBJ: Clinical Practice #1

TOP: Urinary Collection Bag KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. The nurse is admitting a patient with suspected urolithiasis. An appropriate nursing intervention in the care of such a patient would be to:

a.

place a sieve over the commode.

b.

obtain an order for indwelling urinary catheter.

c.

place a graduated cylinder near the commode.

d.

attach a urinary leg bag.

ANS: A

When a patient is suspected of having urolithiasis (a urinary stone), the urine is strained through a fine sieve.

DIF: Cognitive Level: Application REF: p. 540 OBJ: Clinical Practice #1

TOP: Strained Urine Specimen KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

8. When the patient who has an order to be out of bed complains of feeling too weak to walk to the bathroom, the nurse assists the patient with urination elimination by:

a.

acquiring a walker so that the patient can go to the bathroom.

b.

using a fracture bedpan and keep the patient flat.

c.

obtaining a raised toilet seat.

d.

placing a commode at the bedside.

ANS: D

A bedside commode allows the patient to get out of bed to void and does not tire the patient who feels weak. Allowing a weak patient to ambulate unassisted puts the patient at risk for a fall.

DIF: Cognitive Level: Application REF: p. 541 OBJ: Clinical Practice #4

TOP: Urinary Elimination KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

9. A nurse is observing a nursing assistant offering a bedpan to a patient. The nurse will intervene if the nursing assistant:

a.

closes the bedside curtain.

b.

dons clean gloves.

c.

keeps the head of the bed flat after placing the bedpan.

d.

asks the patient to bend his knees and press down with his feet.

ANS: C

The head of the bed should be raised to 30 degrees after the bedpan is placed unless specifically contraindicated.

DIF: Cognitive Level: Application REF: p. 544, Skill 29-1

OBJ: Clinical Practice #4 TOP: Assisting with Toileting

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

10. The nurse can assist a patient who needs to void but cannot begin the urinary stream by:

a.

running water in a nearby sink.

b.

pouring cool water over the perineum.

c.

inserting an indwelling catheter.

d.

distracting the patient with conversation.

ANS: A

The sound of running water helps a patient start voiding.

DIF: Cognitive Level: Application REF: p. 546 OBJ: Theory #3

TOP: Strategies to Assist with Voiding KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

11. An adult male patient who cannot void has an order to have a urinary catheter inserted. Which size catheter would be most appropriate to use?

a.

12 French

b.

16 French

c.

18 French

d.

22 French

ANS: C

The average-sized urinary catheter used for an adult male is 18 to 20 French.

DIF: Cognitive Level: Knowledge REF: p. 547 OBJ: Theory #4

TOP: Indwelling Catheter KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

12. An elderly male patient needs to have a condom catheter applied. An appropriate technique is to:

a.

shave the perineal area before beginning.

b.

apply povidone-iodine to the penis before catheter application.

c.

apply an adhesive strip in a circle around the base of the penis.

d.

leave 1 to 2 inches between the tip of the penis and the drainage part of the catheter.

ANS: D

The catheter is placed so that 1 to 2 inches of space are left to allow for urine to drain away from the penis.

DIF: Cognitive Level: Comprehension REF: p. 548, Skill 29-2

OBJ: Theory #6 TOP: Condom Catheter

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

13. A patient who underwent prostate surgery is admitted to the surgical unit with a catheter that is used to provide continuous irrigation. The nurse recognizes this catheter is a(n):

a.

Alcock.

b.

Malecot.

c.

Coud catheter.

d.

de Pezzer catheter.

ANS: A

An Alcock catheter is used for bladder irrigation following prostate surgery.

DIF: Cognitive Level: Knowledge REF: p. 547 OBJ: Theory #5

TOP: Continuous Bladder Irrigation KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

14. A nurse is cleansing the perineal area of a female patient who is having a urinary catheter inserted. The nurse should use the last povidone-iodinesoaked cotton ball to cleanse downward over the:

a.

urinary meatus.

b.

left labia.

c.

right labia.

d.

perirectal area.

ANS: A

The urinary meatus is cleansed after the labia on each side are cleansed.

DIF: Cognitive Level: Comprehension REF: p. 550, Skill 29-3

OBJ: Clinical Practice #5 TOP: Catheterizing the Female Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

15. When attempting to catheterize a male patient, there is resistance to catheter insertion. The nurses initial intervention should be to:

a.

withdraw the catheter and start over.

b.

ask the patient to take a deep breath.

c.

ask the patient to bear down and hold his breath.

d.

ask that the patient lie on the right side.

ANS: B

If resistance is met, the catheter should be twisted, and the patient should be asked to take a deep breath, which relaxes the urinary sphincter.

DIF: Cognitive Level: Application REF: p. 553, Skill 29-3

OBJ: Clinical Practice #5 TOP: Catheterizing the Male Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

16. A patient has just had a urinary drainage catheter removed. The nurse plans to measure intake and output for this patient for another _____ hours.

a.

1 to 2

b.

4 to 6

c.

6 to 8

d.

12 to 24

ANS: D

Measuring intake and output for 12 to 24 hours after catheter removal allows time to note whether the bladder is draining adequately.

DIF: Cognitive Level: Application REF: p. 557 OBJ: Clinical Practice #1

TOP: Removal of Indwelling Catheter KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

17. A male patient who suffered a spinal cord injury is learning to perform self-urinary catheterization before being discharged to home. The statement made by the patient that indicates more instruction is needed is:

a.

It is a sterile procedure.

b.

The catheter should be pinched before it is withdrawn.

c.

The penis is lifted to a 60- to 90- degree angle for catheter insertion.

d.

The procedure is done sitting on the toilet.

ANS: A

Urinary catheterization in the home after spinal cord injury is usually a clean procedure rather than a sterile one.

DIF: Cognitive Level: Analysis REF: p. 558, Patient Teaching

OBJ: Theory #4 TOP: Self-Catheterization

KEY: Nursing Process Step: Application

MSC: NCLEX: Physiological Integrity: basic care and comfort

18. An adult patient has an order to have his urinary catheter irrigated with normal saline. The nurse plans to draw up how much solution into the sterile irrigation syringe?

a.

1 to 20 mL

b.

20 to 30 mL

c.

30 to 40 mL

d.

50 to 60 mL

ANS: C

The appropriate amount of solution to draw into the syringe for irrigation is 30 to 40 mL in an adult patient, which provides effective irrigation without risking overdistention of the bladder.

DIF: Cognitive Level: Application REF: p. 559, Skill 29-5

OBJ: Theory #4 TOP: Bladder Irrigation

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

19. A nurse irrigating a patients indwelling urinary catheter should instill normal saline as ordered, and then:

a.

unclamp the tubing and lower the collection bag.

b.

massage the patients bladder.

c.

ask the patient to take a deep breath and hold it.

d.

keep the tubing clamped for 30 to 45 minutes.

ANS: A

Immediately after irrigating a urinary catheter, the tubing should be unclamped and the collection bag lowered below the level of the bladder for proper drainage.

DIF: Cognitive Level: Application REF: p. 559, Skill 29-5

OBJ: Theory #4 TOP: Irrigation KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

20. A nurse is reinforcing instructions about Kegel exercises with a female patient. An appropriate instruction is to:

a.

do the exercises 12 times each day.

b.

hold each muscle contraction for a count of 3 seconds.

c.

tighten the abdominal muscles.

d.

tighten the pelvic muscles.

ANS: D

Kegel exercises involve tightening the pelvic muscles to reduce the likelihood of urinary incontinence.

DIF: Cognitive Level: Application REF: p. 562, Patient Teaching

OBJ: Clinical Practice #7 TOP: Kegel Exercises

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

21. A nurse is documenting the removal of a urinary drainage catheter from an assigned patient. If the catheter is removed at 9:00 AM, the nurse recognizes that the patient is due to void by:

a.

11:00 AM.

b.

12 noon.

c.

5:00 PM.

d.

9:00 PM.

ANS: C

Documentation of removal of a urinary catheter should include the time the patient is due to void, which is within 8 hours.

DIF: Cognitive Level: Comprehension REF: p. 564 OBJ: Clinical Practice #1

TOP: Voiding After Urinary Drainage Catheter Removal

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

22. A patient with a history of cystitis had surgery 24 hours ago and is now unable to void. A bladder scan indicates that he has approximately 400 mL of retained urine. The nurse anticipates that the least invasive intervention the physician will order would be:

a.

inserting an indwelling Foley catheter.

b.

monitoring intake and output.

c.

obtaining a midstream specimen.

d.

applying Creds maneuver to the bladder.

ANS: D

Creds maneuver is less invasive and may be used before invasive measures are taken. The bladder is gently massaged from the top of the bladder and rocking the palm of the hand steadily downward.

DIF: Cognitive Level: Application REF: p. 546 OBJ: Clinical Practice #4

TOP: Plan of Care KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

23. A nurse is caring for a patient with prostate enlargement who has an indwelling catheter. As the nurse is attaching a portion of the catheter to the patients abdomen, the patient asks why this is being done. The correct response is:

a.

Taping the catheter to your abdomen will prevent pulling on the meatus.

b.

The catheter cant be pulled out if it is taped to your abdomen.

c.

Taping it in this way enhances the draining of your bladder.

d.

This will prevent the Foley catheter from kinking.

ANS: A

When the catheter is taped to the abdomen, it prevents pulling on the meatus, thus decreasing irritation.

DIF: Cognitive Level: Comprehension REF: p. 552, Skill 29-3

OBJ: Clinical Practice #5 TOP: Catheter Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

24. A nurse instructing a female patient on obtaining a clean catch urine specimen should stress to:

a.

spread the labia apart and clean the center area first.

b.

catch the middle portion of urine after voiding a small amount into the toilet.

c.

carefully collect the urine in the container as soon as the urine stream starts.

d.

fill the urine cup to the brim to ensure an adequate sample.

ANS: B

The procedure for a midstream or clean-catch urine specimen is to void a small amount of urine into the toilet and to catch the middle portion of urine by moving the container into the stream.

DIF: Cognitive Level: Comprehension REF: p. 539 OBJ: Clinical Practice #2

TOP: Clean-Catch Urine Specimen KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

25. A patient is being assessed for a possible urinary tract infection in the outpatient clinic. Before sending a urinalysis specimen to the laboratory, the nurse collects a small amount of urine in order to perform a dipstick test in order to detect:

a.

protein.

b.

glucose.

c.

leukocytes.

d.

ketones.

ANS: C

A dipstick test is performed to test for different components and, in this case, for white blood cells or leukocytes, which indicate an infection. The accurate timing of the reading is essential to the accuracy of the result.

DIF: Cognitive Level: Analysis REF: p. 539 OBJ: Clinical Practice #2

TOP: Dipstick Test KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

COMPLETION

26. The nurse should provide enough hydration for the patient so that the patient can void at least every _______ hours.

ANS:

8

eight

Each patient should void at least every 8 hours unless there is a catheter in place.

DIF: Cognitive Level: Knowledge REF: p. 539 OBJ: Clinical Practice #1

TOP: Frequency of Urination KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

MULTIPLE RESPONSE

27. A nurse instructing a patient about how to prevent recurrent cystitis would include: (Select all that apply.)

a.

increase fluid intake to 2500 to 3000 mL/day.

b.

consume more citrus fruits and juice.

c.

wear cotton underwear.

d.

wipe the rectal area from front to back after a bowel movement.

e.

avoid sitting in a wet bathing suit for extended periods.

f.

empty the bladder every 2 to 3 hours.

ANS: A, C, D, E, F

Cystitis and other urinary tract infections may be avoided by increasing fluid intake to 2500 to 3000 mL/day, avoiding citrus fruits and juice because they cause alkaline urine (bacteria grow more readily in alkaline urine); always wiping the rectal area from front to back after a bowel movement; wearing cotton underwear; not sitting around in a wet bathing suit for extended periods; and emptying the bladder every 2 to 3 hours to prevent stasis and potential for bacteria to multiply if present.

DIF: Cognitive Level: Application REF: p. 537, Health Promotion

OBJ: Theory #3 TOP: Infection Prevention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

28. A patients urinalysis results are available. Which of the following are considered normal characteristics? (Select all that apply.)

a.

Straw-colored

b.

Specific gravity (SpG), 1.015

c.

pH, 6.0

d.

RBCs, more than 1 per high-power field

e.

Cloudy appearance

ANS: A, B, C

Urine is normally straw colored; SpG and pH are within normal range; RBCs are abnormal findings; and cloudy urine may indicate a large amount of protein.

DIF: Cognitive Level: Knowledge REF: p. 537 OBJ: Theory #2

TOP: Urinalysis KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: basic care and comfort

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