Fundamentals of Nursing Test 3 Review Questions- Chp. 47 Urinary Elimination

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1. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?

1. The bladder distends and its capacity increases.
2. Older adults ignore the need to void.
3. Urine becomes more concentrated.
4. The amount of urine retained after voiding increases
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Terms in this set (10)
1. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?

1. The bladder distends and its capacity increases.
2. Older adults ignore the need to void.
3. Urine becomes more concentrated.
4. The amount of urine retained after voiding increases
Answer: 4.

Rationale: The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained
2. During assessment of the client with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.

1. Perineal skin irritation
2. Fluid intake of less than 1500 mL/day
3. History of antihistamine intake
4. History of frequent urinary tract infections
5. A fecal impaction
Answer: 1, 2, 4, and 5.

Rationale: The perineum may become irritated by the frequent contact with urine.

*Normal fluid intake is at least 1500 mL/day and clients often decrease their intake to try to minimize urine leakage.

*UTI scan contribute to incontinence.

*A fecal impaction can compress the urethra, which can result in small amounts of urine leakage
3. Which action represents the appropriate nursing management of a client wearing an external urinary device?

1. Ensure that the tip of the penis fits snugly against the end of the condom.
2. Check the penis for adequate circulation 30 minutes after applying.
3. Change the condom every 8 hours.
4. Tape the collecting tubing to the lower abdomen"
Answer: 2.

Rationale: The penis and condom should be checked one-half hour after application to ensure that it is not too tight.
4. The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?

1. Leaves the catheter in place and gets a new sterile catheter
2. Leaves the catheter in place and asks another nurse to attempt the procedure.
3. Removes the catheter and redirects it to the urinary meatus.
4. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus
Answer: 1.

Rationale: The catheter in the vagina is contaminated and cannot be reused.

If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus.
5. You have explained to the client the reason for and steps involved for insertion of an indwelling urinary catheter. List the following actions in the correct sequence:

1. Apply sterile gloves
2. Attach prefilled syringe
3. Secure IUC appropriately to prevent urethural irritation
4. Perform pericare
5. Insert catheter to appropriate length and check urine flow
6. Lubricate catheter
7. Inflate balloon
8. Perform hand hygiene
9. Clean urinary meatus with antiseptic solution
10. Open catheter kit

1. 8, 10, 4, 1, 2, 6, 9, 5, 7, 3
2. 2, 4, 8, 10, 1, 6, 2, 9, 5, 7, 3
3. 4, 8, 1, 10, 6, 2, 9, 5, 7, 3
4. 10, 4, 8, 1, 7, 2, 6, 9, 5, 3
Answer: 2.

Rationale: Option 2 is the correct sequence.

Option 1 is incorrect because the nurse needs to perform hand hygiene after providing pericare.

Option 3 is incorrect because the outside of the kit is not sterile and the nurse would not open the kit with sterile gloves.

The current best practice is to not pre-inflate the balloon
6. During shift report, the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which specific type of urinary incontinence is the most appropriate for the nursing diagnosis?

1. Stress
2. Reflex
3. Functional
4. Urge
Answer: 4.

Rationale: The key phrase is "the urge to void."
7. A female client has a urinary tract infection (UTI). Which teaching points by the nurse would be helpful to the client? Select all that apply.

1. Limit fluids to avoid the burning sensation on urination.
2. Review symptoms of UTI with the client.
3. Wipe the perineal area from back to front.
4. Wear cotton underclothes.
5. Take baths rather than showers
Answer: 2 and 4.

Rationale: Option 2 validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth
8. The nurse will need to assess the client's performance of clean intermittent catheterization (CIC) for a client with which urinary diversion?

1. Ileal conduit
2. Kock pouch
3. Neobladder
4. Vesicostomy"
Answer: 2
9. Which focus is the nurse most likely to teach for a client with a flaccid bladder?

1. Habit training: Attempt voiding at specific time periods.
2. Bladder retraining: Delay voiding according to a pre-schedule timetable.
3. Credé's maneuver: Apply gentle manual pressure to the lower abdomen.
4. Kegel exercises: Contract the pelvic floor muscles"
Answer: 3.

Rationale: Because the bladder muscles will not contract to increase the intra bladder pressure to promote urination, the process is initiated manually
10. Which of the following behaviors indicates that the client on a bladder retraining program has met the expected outcomes? Select all that apply.

1. Voids each time there is an urge.
2. Practices slow, deep breathing until the urge decreases.
3. Uses adult diapers, for "just in case."
4. Drinks citrus juices and carbonated beverages.
5. Performs pelvic floor muscle exercises.
Answer: 2 and 5.

Rationale: It is important for the client to inhibit the urge-to-void sensation when a premature urge is experienced.