Nursing Exam 3 Fundamentals Study Guide Questions with Answers, Study notes of Nursing

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Nursing Exam 3 Fundamentals Study Guide

Questions with Answers

A residual urine test is prescribed for a client with benign prostatic hyperplasia. What should the nurse instruct the client to do? Void after a urinary catheter is removed. Collect a specimen of urine during midstream. Attempt to void when a urinary catheter is in place. Empty the bladder before a urinary catheter is inserted. Emptying the bladder before a urinary catheter is inserted measures how much urine remains in the bladder after voiding. Residual urine is the urine left in the bladder after urinating. After voiding, the client is catheterized, or a bladder scan can be used. The bladder will be empty of urine when the urinary catheter is removed. Collecting a specimen of urine during midstream is known as a clean-catch, or midstream, urine specimen, not a residual urine test. The urinary catheter will prevent urine accumulation. A primary healthcare provider prescribed an indwelling urinary catheter for a client. Which catheter should the nurse use to implement this prescription? Option C is an indwelling urinary catheter [1][2]; it has two lumens. One lumen is used to inflate the balloon at the tip of the catheter; this holds the catheter in place. The other lumen allows the continuous drainage of urine from the bladder via gravity into a collection bag. Option A is a simple one-lumen urethral catheter. It is used to empty the bladder of urine or to obtain a sterile urine specimen. It is inserted once, removed, and discarded. Option B is a mushroom- tipped Pezzar catheter that is used for suprapubic catheterization. Option D is a triple-lumen urinary catheter; it is used for continuous bladder irrigations. One lumen is used to inflate the balloon at the tip of the catheter. The second lumen is used to continuously instill a solution into the bladder. The third lumen allows the continuous drainage of fluid from the bladder via gravity into a collection bag. What is the most important intervention to prevent hospital-acquired catheter- associated urinary tract infections (CAUTIs)? Removing the catheter Keeping the drainage bag off of the floor Washing hands before and after assessing the catheter Cleansing the urinary meatus with soap and water daily

Research demonstrates that decreasing the use of indwelling urinary catheters is the most important intervention to prevent hospital-acquired catheter-associated urinary tract infections (CAUTIs). Keeping the drainage bag off the floor, washing hands before and after assessing the catheter, and cleansing the urinary meatus daily with soap and water will help reduce infections; however, these are not the most important interventions to prevent CAUTIs. The nurse understands that the best way to reduce catheter-associated urinary tract infections (CAUTIs) in long-term indwelling catheters is to do what? Perform catheter care twice a day. Replace the catheter on a routine basis. Administer cranberry tablets three times each day. Give antibiotics for the duration of catheter placement. A bacterial biofilm develops in long-term indwelling catheters increasing the risk of catheter- associated urinary tract infection (CAUTI). The best way to eliminate this risk is to perform routine perineal hygiene and catheter care every day. Routine replacement of indwelling urinary catheters increases CAUTI risk. The efficacy of cranberry tablets in decreasing the frequency of urinary tract infections has not been established. Antibiotic therapy may increase the growth of microbes within the biofilm. A nurse is caring for an older bedridden male client who is incontinent of urine. Which action should the nurse take first? Restrict fluid intake. Offer the urinal regularly. Apply incontinence pants. Insert an indwelling urinary catheter. Offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence; also it promotes skin breakdown and can lower self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection. Also, it requires a primary healthcare provider’s prescription. A urine specimen is needed to test for the presence of ketones in a diabetic client. What should the nurse do when collecting this specimen from a urinary catheter? Disconnect the catheter, and drain the urine into a clean container. Clean the drainage valve, and remove the urine from the catheter bag. Wipe the catheter with alcohol, and drain the urine into a sterile test tube. Clamp the catheter, cleanse the port, and use a sterile syringe to remove urine. The urinary catheter and drainage bag should always remain a closed, sterile system; urine should be drawn only from the catheter port, not the collection bag. Cleaning the drainage valve and removing the urine from the catheter bag will not yield a fresh specimen indicating present

the

urine following each voiding before adding the urine to the container is not necessary; this is done for clients with renal calculi. The nurse is instructing a female client how to collect a urine specimen. What should the nurse tell the client about obtaining the specimen? "Start urinating in the cup and then finish urinating in the toilet." "If you can’t fill the cup then leave it on the toilet and use it again when you next void." "With the enclosed towelettes, wipe your labia from front to back before collecting the specimen." "When you finish, leave the cup on the back of the toilet and the aide will get it when making rounds." The client must use the packaged towelettes and wipe the labia from front to back before urinating. The client needs to urinate a small amount in the toilet first and then hold the cup under the perineal area and finish urinating in the cup. If the client cannot void enough for a specimen, the insufficient sample should be discarded and another specimen obtained when the client can void a sufficient amount. The client should notify the nurse immediately after the specimen is collected so it can be sent to the laboratory for analysis. A nurse provides education to a client about how to prevent constipation. The nurse concludes that the teaching is understood when the client makes which statements? Select all that apply. "I may eat potatoes at dinner daily." "I should drink at least six glasses of water every day." "I must eat eggs for breakfast three times a week." "I can include bran muffins in my breakfast daily." "I will walk every day as part of my exercise regimen." At least six glasses of water keeps the feces soft, which prevents constipation. Whole grains such as bran muffins are high in roughage, which prevents constipation. Walking increases intestinal motility, which helps prevent constipation. Potatoes and eggs do not contain roughage and will not prevent constipation. A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? Presence of distention Extent of weight gained Amount of high-fiber food consumed Length of time this problem has existed First, the nurse should establish when the client last defecated because the client may have perceived constipation. Abdominal distention may or may not be observed with constipation. Weight gain has no relationship to constipation. Although lack of bulk in the diet can lead to

A client appears depressed since the surgical creation of a colostomy five days ago. The nurse determines that there is some movement toward adaptation to the change in body image when the client exhibits which behavior? Discusses the necessity of the colostomy Requests the nurse to change the dressing Looks at the face of the nurse during care Stares at the stoma during dressing changes A willingness to view the stoma indicates the beginning of acceptance and integration of the colostomy into the body image. Discussing the necessity of the colostomy is evidence of intellectualization rather than acceptance of the change in body image. Requesting the nurse to change the dressing indicates lack of readiness to participate in the care of the stoma. Watching the face of the nurse during the care indicates that the client is observing the staff's response to and acceptance of the stoma and, by extension, the client as an individual. A client with the diagnosis of ulcerative colitis has surgery for the creation of an ileostomy. Postoperatively, for which potential life-threatening complication should the nurse assess the client? Wound infection Ischemia of the stoma Electrolyte imbalances Excoriation of skin around the stoma An ileostomy directs liquid feces out of the body, bypassing the large intestine, where fluid and electrolytes normally are reabsorbed. The continuous excretion of liquid feces may deplete the body of fluid and electrolytes, resulting in a life-threatening fluid deficit and electrolyte imbalance. Although a wound infection is always a possibility after surgery, it is unlikely and not life threatening. Although the stoma should be assessed to ensure that it is not dark, but pink and moist, which indicates adequate circulation, this complication is unlikely and not life threatening. Although impaired skin integrity can occur when liquid feces remain on the skin surrounding the stoma, this should not occur if an appliance to collect the discharge is used correctly. Also, impaired skin integrity is not a life-threatening complication. When providing care for a client who is receiving enteral feedings via a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication? Skin breakdown Aspiration pneumonia Retention ileus Profuse diarrhea Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi- Fowler or higher. Skin breakdown in a client with an NG tube may result from pressure of the tube

against nasal structures. The tube should be periodically repositioned and taped to prevent this complication. A retention ileus is not related to an NG tube. A client who develops profuse diarrhea with an NG tube requires further investigation. It may be totally unrelated or a result of an enteral feeding incompatibility. Which represents appropriate nursing management of the client's nasogastric (NG) tube in the immediate postoperative period following gastroduodenostomy? Advancing the tube to the original insertion depth if the tube becomes dislodged. Obtaining a prescription to vigorously irrigate the nasogastric tube if clogging is noted. Carefully monitoring the nasogastric tube to ensure that the tube is patent and the suction is working. Reporting the presence of bright red gastric aspirant in the suction canister during the immediate postoperative period. Ensuring that the nasogastric tube is patent and that the suction is working properly are priorities for the postoperative client to prevent retention of gastric secretions that may lead to abdominal distention, nausea, vomiting, and further serious complications. Advancing the tube to the original insertion depth if the tube becomes dislodged is not recommended. Improper reinsertion may result in the aspiration of gastric contents. Vigorous irrigation of the nasogastric tube, even if clogged, is not recommended because this can cause damage to the gastric mucosa. Finally, the presence of bright red gastric aspirant in the suction canister for the first 24 hours after surgery is a normal finding in the postoperative period. Which client response during the insertion of a nasogastric tube indicates to the nurse that the client is experiencing serious difficulty with the insertion? Choking Redness Gagging Cyanosis If the nasogastric tube is passed accidentally into the trachea rather than the esophagus, it will obstruct the airway, causing cyanosis; this is a serious problem that must be corrected immediately. Choking may occur as the tube passes through the back of the throat; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Facial flushing (floridity) may result if the client attempts to fight the passage of the tube; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. Gagging may occur as the tube passes from the nasal passage through the pharynx; this commonly occurs with insertion of a nasogastric tube and is a temporary problem. A client with dementia and a percutaneous endoscopic gastrostomy (PEG) tube is being cared for at home. Which action provides evidence that a family member is effectively managing the client's care? Empty feeding bag stays attached to the tubing. Tube is flushed with air after medication is given.

activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.

A registered nurse is educating a nursing student about the primary level of prevention. What information should the nurse provide? Select all that apply. Primary prevention is also known as true prevention. Primary prevention is applied to clients who are considered physically and emotionally healthy. Primary prevention is directed towards rehabilitative care rather than diagnosis and treatment. Primary prevention activities enable clients to return to a normal level of health as early as possible. Primary prevention includes health education programs, immunizations, and physical and nutritional fitness activities. Primary prevention is also known as true prevention as it precedes disease and dysfunction. Primary prevention is applied on those clients who are considered to be physically and emotionally healthy. Primary prevention focuses on health promotion. This includes health education programs, immunizations, and physical and nutritional fitness activities. Tertiary prevention is directed towards providing rehabilitative care to clients rather than diagnosis and treatment. Secondary prevention activities enable clients to return to a normal level of health as early as possible. A nurse is educating a client about the tertiary level of prevention. What information should the nurse provide? Select all that apply. Tertiary prevention focuses on preventing complications of illness. Tertiary prevention helps clients achieve as high a level of functioning as possible. Tertiary prevention aims at minimizing the effects of long-term disease or disability. Tertiary prevention is applied when the client is physically and emotionally healthy. Tertiary prevention activities are aimed at diagnosis and treatment instead of rehabilitation. Tertiary prevention is also known as preventive care since it aims at preventing further disability or reduced functioning in the clients. Even though clients may have developed limitations due to illness or impairment, tertiary prevention helps in achieving as high a level of functioning as possible. Tertiary prevention makes use of interventions that prevent complications and deteriorations in order to minimize the effects of long-term disease or disability. Tertiary prevention is applied when the client has a defect or disability that is permanent and irreversible. Tertiary prevention activities focus on rehabilitative care instead of diagnosis and treatment. The nurse is performing nursing care therapies and including the client as an active participant in the care. Which basic step is involved in this situation? Planning Evaluation Assessment Implementation

the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client’s health and situation during the assessment stage. A nurse is evaluating a client’s response to fluid replacement therapy. Which clinical finding indicates successful replacement? Urinary output of 30 mL in an hour Central venous pressure reading of 1.5 mm Hg Baseline pulse rate of 120 beats/min that decreases to 110 beats/min within a 15-minute period Baseline blood pressure of 50/30 mm Hg that increases to 70/40 mm Hg within a 30- minute period A urinary output rate of 30 mL/hour is considered adequate for perfusion of the kidneys, heart, and brain. A central venous pressure reading of 1.5 mm Hg indicates hypovolemia. A baseline pulse rate of 120 beats/min that decreases to 110 beats/min within a 15-minute period and a baseline blood pressure of 50/30 mm Hg that increases to 70/40 mm Hg within a 30-minute period indicate improvement but not necessarily adequate tissue perfusion.

Chapter 46- Urinary Elimination

Organs of the Urinary System:

• Kidneys-^ remove^ waste^ from^ the^ blood^ to^ form^ urine
• Ureters- transport urine from the kidneys to the bladder
• Bladder- reservoir for urine until the urge to urinate develops
• Urethra- urine travels from the bladder and exits through the urethral meatus Physical Assessment:
• Skin^ and^ mucosal^ membranes o (^) Asses hydration
• Kidneys o (^) Flank pain may occur with infection or inflammation
• Bladder o (^) Distended bladder rises above symphysis pubis
• Urethral^ Meatus o (^) Observer for discharge, inflammation, and lesions Assessment of Urine:
• Intake^ and^ output-^30 mL/hr^ as^ minimum
• Color-^ pale^ straw^ to^ amber^ color
• Clarity-^ assessing^ for^ bacteria,^ protein,^ and^ blood;^ transparent^ unless^ pathology is (^) present
• Odor-^ ammonia^ in^ nature

Common Urinary Problems

• Urinary^ retention-^ accumulation^ of^ urine^ due^ to^ the^ inability^ of^ the^ bladder^ to empty; (^) patients feel pressure, discomfort, and pain o (^) PVR (post void residual)- the amount of urine left in the bladder after voiding
• Urinary tract infection- bacteria in urinary tract; can result from catheterization or procedure; most common HAI; E. Coli found in colon is the most common causative pathogen; treated with antibiotics
• Urinary incontinence- involuntary leakage of urine
• Urinary diversions- diversion of urine to external source o (^) Care- inspect the client’s stoma regularly; keep skin dry and clean; measure input and outputs; watch for mucous in the urine from an ileal conduit; make sure patient can participate in care
• Hematuria-^ blood^ in^ urine
• Pyelonephritis-^ kidney^ infection Indications for Use of Bladder Scanner:
• Urinary frequency
• Absent or decreased urine output
• Bladder^ distention
• Inability^ to^ void
• Establishing^ intermittent^ catherization^ schedule Factors that affect urination- can be acute (reversible) or chronic (irreversible):
• Pre-renal:^ decreased^ blood^ flow^ to^ and^ through^ the^ kidneys
• Renal:^ disease^ condition^ of^ the^ renal^ tissue
• Post-renal:^ obstruction^ in^ the^ lower^ urinary^ tract^ that^ prevents^ blood^ flow^ from the (^) kidneys
• Diseases^ that^ affect^ urination: o (^) Diabetes mellitus o (^) Multiple sclerosis o (^) BPH o (^) Alzheimer’s disease o (^) Parkinson’s disease o (^) Degenerative joint disease
• Psychological^ factors^ like^ anxiety^ and^ emotional^ stress
• Fluid balances maintain the balance between retention and excretion of fluids
• Caffeine increases urine formation and alcohol increases water loss in urine
• Fever causes highly concentrated and reduced urine volume Types and uses of urethral catheters:
• Intermittent^ ureteral^ catheters-^ used^ to^ drain^ bladder^ for^ shorter^ periods^ (5^ to 10 minutes)

3. Washing with soap and water before applying the condom-type catheter

4. Applying tape to the condom sheath to keep it securely in place 5. Which instructions should the nurse give the nursing assistive personnel (NAP) concerning a patient who has had an indwelling urinary catheter removed that day?
5. Limit oral fluid intake to avoid possible urinary incontinence.
6. Expect patient complaints of suprapubic fullness and discomfort. 3. Report the time and amount of first voiding.
7. Instruct patient to stay in bed and use a urinal or bedpan. 6. A postoperative patient with a three-way indwelling urinary catheter and continuous bladder irrigation (CBI) complains of lower abdominal pain and distention. What should be the nurse's initial intervention?
8. Increase the rate of the CBI
9. Assess the intake and output from system
10. Decrease the rate of the CBI
11. Assess vital signs 7. An ambulatory elderly woman with dementia is incontinent of urine. She has poor short- term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?
12. Recommend that she be evaluated for an overactive bladder (OAB) medication
13. Start a scheduled toileting program
14. Recommend that she be evaluated for an indwelling catheter
15. Start a bladder-retraining program 8. What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.)
16. Keep the bowels regular.
17. Limit water intake to 1 to 2 glasses a day. 3. Wear cotton underwear.
18. Cleanse the perineum from front to back.
19. Practice pelvic muscle exercise (Kegel) daily. 9. Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately?
20. Do you leak urine when you cough or sneeze?
21. Do you need help getting to the toilet? 3. Do you dribble urine constantly?
22. Does it burn when you pass your urine? 10. Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.
23. Insert and advance catheter. 5
24. Lubricate catheter. 3
25. Inflate catheter balloon. 7

1. A nurse is teaching a patient about the urinary system. In which order will the nurse present the structures, following the flow of urine? a. Kidney, urethra, bladder, ureters b. Kidney, ureters, bladder, urethra c. Bladder, kidney, ureters, urethra d. Bladder, kidney, urethra, ureters ANS: B The flow of urine follows these structures: kidney, ureters, bladder, and urethra. 2. A nurse is reviewing urinary laboratory results. Which finding will cause the nurse to follow up? a. Protein level of 2 mg/100 mL b. Urine output of 80 mL/hr c. Specific gravity of

d. pH of 6. ANS: C Dehydration, reduced renal blood flow, and increase in antidiuretic hormone secretion elevate specific gravity. Normal specific gravity is 1.0053 to 1.030. An output of 30 mL/hr or less for 2 or more hours would be cause for concern; 80 mL/hr is normal. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease. 3. A patient is experiencing oliguria. Which action should the nurse perform first? a. Assess for bladder distention. b. Request an order for diuretics. c. Increase the patient’s intravenous fluid rate. d. Encourage the patient to drink caffeinated beverages. ANS: A Oliguria is diminished urinary output in relation to fluid intake. The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action. 4. A patient requests the nurse’s help to the bedside commode and becomes frustrated when unable to void in front of the nurse. How should the nurse interpret the patient’s inability to void? a. The patient can be anxious, making it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void.

c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output. ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. Anxiety can impact bladder emptying due to inadequate relaxation of the pelvic floor muscles and urinary sphincter. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological (does not recognize signals or not drinking enough fluids) or psychological (lonely) condition exists.

5. The patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale for the nurse’s action? a. The patient may void uncontrollably during the procedure. b. Local trauma sometimes promotes excessive urine incontinence. c. Anesthetics can decrease bladder contractility and cause urinary retention. d. The patient will not interrupt the procedure by asking to go to the bathroom. ANS: C Anesthetic agents and other agents given during surgery can decrease bladder contractility and/or sensation of bladder fullness, causing urinary retention. Local trauma during lower abdominal and pelvic surgery sometimes obstructs urine flow, requiring temporary use of an indwelling urinary catheter. The patient is more likely to retain urine rather than experience uncontrollable voiding. 6. The nurse, upon reviewing the history, discovers the patient has dysuria. Which assessment finding is consistent with dysuria? a. Blood in the urine b. Burning upon urination c. Immediate, strong desire to void d. Awakes from sleep due to urge to void ANS: B Dysuria is burning or pain with urination. Hematuria is blood in the urine. Urgency is an immediate and strong desire to void that is not easily deferred. Nocturia is awakening form sleep due to urge to void. 7. An 86-year-old patient is experiencing uncontrollable leakage of urine with a strong desire to void and even leaks on the way to the toilet. Which priority nursing diagnosis will the nurse include in the patient’s plan of care? a. Functional urinary incontinence b. Urge urinary incontinence c. Impaired skin integrity d. Urinary retention ANS: B