Chapter 45: Urinary Elimination Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

MULTIPLE CHOICE

1. The nurse determines that the nursing diagnosis stress urinary incontinence related to decreased pelvic muscle tone is the most appropriate for an oriented adult female client. A therapeutic nursing intervention based on this diagnosis is to:

1.

Apply adult diapers

2.

Catheterize the client

3.

Administer Urecholine

4.

Teach Kegel exercises

ANS: 4

Pelvic floor exercises, also known as Kegel exercises, improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups. These exercises have demonstrated effectiveness in treating stress incontinence, overactive bladders, and mixed causes of urinary continence. The client is oriented and therefore could be taught Kegel exercises to improve pelvic floor muscle tone. Applying adult diapers does not improve the clients problem of incontinence and places the client at risk for skin breakdown. Because bladder catheterization carries the risk for urinary tract infection (UTI), it is preferable to rely on other measures for management of incontinence. The nurse can support the use of Kegel exercises as an inexpensive nonpharmacological intervention to reduce the clients stress incontinence. Bethanechol (Urecholine) stimulates the parasympathetic nervous system to promote complete bladder emptying and is primarily used to treat urinary retention and possible overflow incontinence. Nonpharmacological approaches should be attempted before pharmacological approaches are taken.

DIF: A REF: 1148 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

2. Which of the following statements should the nurse use to instruct the nursing assistant caring for a client with an indwelling urinary catheter?

1.

Empty the drainage bag at least every 8 hours.

2.

Clean up the length of the catheter to the perineum.

3.

Use clean technique to obtain a specimen for culture and sensitivity.

4.

Place the drainage bag on the clients lap while transporting the client to testing.

ANS: 1

The urinary drainage bag should be emptied at least every 8 hours. If large outputs are noted, more frequent emptying will be required. The perineum should be cleansed and then down the catheter for a length of approximately 10 cm (4 inches). Only use sterile technique to collect specimens from a closed drainage system. Avoid raising the drainage bag above the level of the bladder. If it becomes necessary to raise the bag during transfer of the client to a bed or stretcher, clamp the tubing or empty the tubing contents to the drainage bag first. The drainage bag can be attached to the wheelchair below the level of the clients bladder for transport. It should not be placed on the clients lap.

DIF: A REF: 1164 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

3. The nurse suspects that the client has a bladder infection based on the clients exhibiting an early sign or symptom such as:

1.

Chills

2.

Hematuria

3.

Flank pain

4.

Incontinence

ANS: 2

Irritation to the bladder and urethral mucosa results in blood-tinged urine (hematuria). Hematuria is a sign of a bladder infection. Chills are a more systemic symptom associated with pyelonephritis. Flank pain is a more systemic symptom associated with pyelonephritis. Incontinence is not a symptom of a bladder infection.

DIF: A REF: 1134 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

4. When obtaining a sterile urine specimen from an indwelling urinary catheter the nurse should:

1.

Disconnect the catheter from the drainage tubing

2.

Withdraw urine from a urinometer

3.

Open the drainage bag and removing urine

4.

Use a needle to withdraw urine from the catheter port

ANS: 4

A sterile specimen can be obtained through the special port found on the side of the indwelling catheter. The nurse clamps the tubing below the port, allowing fresh, uncontaminated urine to collect in the tube. After the nurse wipes the port with an antimicrobial swab, a sterile syringe needle is inserted, and at least 3 to 5 mL of urine is withdrawn. Using sterile technique, the nurse transfers the urine to a sterile container. The catheter should not be disconnected from the drainage tubing. The system should remain a closed system to prevent infection. A urinometer is a device used to determine the specific gravity of urine. It is not a sterile device and should not be used for obtaining a sterile urine specimen. Urine should not be obtained from a drainage bag for a specimen, because the urine would not be fresh and would be contaminated from microorganisms in the drainage bag.

DIF: A REF: 1140 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

5. Immediately after an intravenous pyelogram (IVP) the nurse should observe the client for which of the following?

1.

Infection in the urinary bladder

2.

An allergic reaction to the contrast material

3.

Urinary suppression caused by injury to kidney tissues

4.

Incontinence as a result of paralysis of the urinary sphincter

ANS: 2

After an IVP the nurse should encourage fluid intake to dilute and flush dye from the client and observe the client for late symptoms of allergy (e.g., rash). There is no increased risk for infection of the urinary bladder from an IVP. This would be more likely with an invasive procedure, such as an endoscopy (cystoscopy). An IVP should not injure tissues of the kidney or cause paralysis of the urinary sphincter.

DIF: A REF: 1145 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

6. A client with an excessive alcohol intake has a reduced amount of antidiuretic hormone (ADH). The nurse anticipates the client will exhibit:

1.

Hematuria

2.

An increased blood pressure

3.

Dry mucous membranes

4.

A low serum sodium level

ANS: 3

Alcohol inhibits the release of ADH, resulting in increased water loss in urine. The client may show signs of decreased fluid volume (dehydration), including dry mucous membranes. The effects of excessive alcohol intake and reduced antidiuretic hormone will not cause hematuria. Having decreased levels of antidiuretic hormone will lead to increased urine production. The client may exhibit a decreased blood pressure resulting from decreased fluid volume and an increased serum sodium level with dehydration.

DIF: A REF: 1133 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

7. A client is going to have a cystoscopy. Which of the following reflects the correct information that should be taught before the procedure?

1.

Are you allergic to iodine?

2.

There will be no need to have a special consent form.

3.

You will need to have fluids restricted the evening before the cystoscopy.

4.

You will probably be given sedatives before the procedure.

ANS: 4

Although this procedure may be accomplished using local anesthesia, it is more commonly performed using general anesthesia or conscious sedation to avoid unnecessary anxiety and trauma for the client. A cystoscopy involves direct visualization. No contrast dye is used; therefore the nurse does not need to ask if the client is allergic to iodine. A signed consent form is obtained. Fluids are not restricted before or after the procedure. The flushing action helps remove bacteria from the urethra.

DIF: A REF: 1146 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

8. A postpartum client has been unable to void since her delivery of her baby this morning. Which of the following nursing measures would be beneficial for the client initially?

1.

Increase fluid intake to 3500 mL.

2.

Insert indwelling Foley catheter.

3.

Rinse the perineum with warm water.

4.

Apply firm pressure over the bladder.

ANS: 3

The nurse can pour warm water over the clients perineum and create the sensation to urinate. A client with normal renal function who does not have heart or kidney disease should drink 2000 to 2500 mL of fluid daily. Increasing the clients fluid intake to 3500 mL is excessive. Because bladder catheterization carries the risk for UTI, it should be avoided if possible. The nurse should try other noninvasive measures to promote urination before calling the health care provider for an order to insert a Foley catheter. The nurse should not apply firm pressure over the bladder of a postpartum woman with an intact nervous system. The nurse could create more damage by exerting force on the clients uterus at this time.

DIF: C REF: 1149 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

9. The nurse is visiting the client who has a nursing diagnosis of urinary retention. Upon assessment the nurse anticipates that this client will exhibit:

1.

Severe flank pain and hematuria

2.

Pain and burning on urination

3.

A loss of the urge to void

4.

A feeling of pressure and voiding of small amounts

ANS: 4

With urinary retention, urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the symphysis pubis, restlessness, and diaphoresis. The sphincter temporarily opens to allow a small volume of urine (25 to 60 mL) to escape, with no real relief of discomfort. Severe flank pain and hematuria are supporting data for an upper urinary tract infection (pyelonephritis). Pain and burning on urination are symptoms of a lower urinary tract infection (such as a bladder infection). Supportive data for reflex incontinence would include a loss of the urge to void.

DIF: A REF: 1146 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

10. The unit manager is evaluating the care of a new nursing staff member. Which of the following is an appropriate technique for the nurse to implement in order to obtain a clean-voided urine specimen? 

1.

Apply sterile gloves for the procedure.

2.

Restrict fluids before the specimen collection.

3.

Place the specimen in a clean urinalysis container.

4.

Collect the specimen after the initial stream of urine has passed.

ANS: 4

To collect a clean-voided specimen, the nurse should collect the specimen (30 to 60 mL) after the initial stream of urine has passed. Nonsterile gloves are adequate. Fluids are encouraged so the client will be more likely to be able to void. The specimen should be collected in a sterile container and then placed into a plastic specimen bag.

DIF: A REF: 1142 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

11. The nurse is aware that clients with chronic alterations in kidney function suffer from insufficient amounts of:

1.

Vitamin A

2.

Vitamin D

3.

Vitamin E

4.

Vitamin K

ANS: 2

The kidneys play a role in calcium and phosphate regulation by producing a substance that converts vitamin D into its active form. Clients with chronic alterations in kidney function do not make sufficient amounts of the active vitamin D. Clients with chronic alterations in kidney function do not suffer from an insufficient amount of vitamin A, vitamin E, or vitamin K.

DIF: A REF: 1131 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

12. In an assessment of a client with reflex incontinence the nurse expects to find that the client has:

1.

A constant dribbling of urine

2.

An uncontrollable loss of urine when coughing or sneezing

3.

No urge to void and an unawareness of bladder filling

4.

An immediate urge to void but not enough time to reach the bathroom

ANS: 3

The nurse expects to find the client with reflex incontinence to have no urge to void and an unawareness of bladder filling. A constant dribbling of urine may be seen with overflow incontinence. With stress incontinence the client is unable to control loss of urine when coughing or sneezing. Functional incontinence is seen when there is an immediate urge to void but not enough time to get to the bathroom.

DIF: A REF: 1152 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

13. When calculating the daily intake and output, the nurse anticipates that the urinary output for an average adult should be:

1.

800 to 1000 mL/day

2.

1000 to 1200 mL/day

3.

1500 to 1600 mL/day

4.

2000 to 2300 mL/day

ANS: 3

Although output does depend on intake, the normal adult urine output is 1500 to 1600 mL/day.

DIF: A REF: 1130 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

14. A timed urine specimen collection is ordered. The test will need to be restarted if which of the following occurs?

1.

The client voids in the toilet.

2.

The urine specimen is kept cold .

3.

The first voided urine is discarded.

4.

The preservative is placed in the collection container.

ANS: 1

Missed specimens make the whole collection inaccurate, causing the test to need to be restarted. The urine specimen is kept in a collection container, which may contain preservatives, or the urine may be kept in a collection container on ice. The timed period begins after the client urinates. The first voided urine is discarded, and then the time for collection begins.

DIF: A REF: 1140 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

15. The nurse is working with a client who has a urinary diversion. Included in the plan of care for this client is instruction that:

1.

Special clothing will need to be ordered in order to fit around the diversion

2.

A stomal bag will only need to be worn at night

3.

A reduction in physical activity will be planned

4.

Special skin care is a priority

ANS: 4

Special skin care is a priority in caring for a client with a urinary diversion. Local irritation and skin breakdown occur when urine comes in contact with the skin for long period. Special clothing is not necessary for the client with a urinary diversion, but the client must wear a stomal pouch continuously because there is no sphincter control for regulation of urine flow. There is no need to plan for a reduction in activity.

DIF: A REF: 1134 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

16. The nurse caring for a client who is receiving closed catheter irrigation instills 950 mL of normal saline irrigant during the shift. There is a total of 1725 mL in the drainage bag. The nurse calculates the clients urinary output for the shift to be:

1.

775 mL

2.

950 mL

3.

1725 mL

4.

2675 mL

ANS: 1

The amount of fluid used to irrigate the bladder and catheter should be subtracted from the total output to determine an accurate urinary output. 1725 mL 950 mL = 775 mL.

DIF: A REF: 1168 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

17. The nurse caring for a client in an extended care facility should provide which intervention in a bladder retraining program?

1.

Providing negative reinforcement when the client is incontinent

2.

Having the client wear adult diapers as a preventative measure

3.

Putting the client on a q2h toilet schedule during the day

4.

Promoting the intake of caffeine to stimulate voiding

ANS: 3

A bladder retraining program includes initiating a toileting schedule on awakening, at least every 2 hours during the day and evening, before getting into bed, and every 4 hours at night. Negative reinforcement should not be used when the client is incontinent. However, positive reinforcement should be provided when continence is maintained. The client should be offered protective undergarments to contain urine and reduce the clients embarrassment (not diapers). Tea, coffee, other caffeine drinks, and alcohol should be minimized.

DIF: A REF: 1171 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

18. A 3-year-old child is visiting the pediatric clinic. The nurse suspects that the child has a urinary tract infection. An appropriate method for the nurse to implement in order to obtain a urine specimen from the child is to:

1.

Use an indwelling catheter

2.

Offer fluids 30 minutes in advance

3.

Apply pressure over the urinary bladder

4.

Place a diaper on the child and squeeze out the specimen

ANS: 2

Offering the young child fluids 30 minutes before requesting a specimen may help. Because bladder catheterization carries the risk for UTI, blockage, and trauma to the urethra, it is preferable to rely on other measures for specimen collection. Applying pressure over the urinary bladder of a child with an intact nervous system will not help and may create more stress in the child. Squeezing urine from a childs diaper is not an accurate method of obtaining a urine specimen to determine whether the child has a urinary tract infection.

DIF: A REF: 1140 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

19. A urine sample is obtained from the client for a routine urinalysis. Upon reviewing the results of the test, the nurse notes that an expected finding of the urinalysis is:

1.

pH 8.0

2.

Specific gravity 1.018

3.

Protein amounts to 12 mg/100 mL

4.

White blood cells (WBCs) 5 to 8 per low-power field casts

ANS: 2

The normal specific gravity of urine is 1.010 to 1.025. The normal urine pH is 4.6 to 8.0, with an average of 6.0. Protein is not normally found in the urine. The normal value for urine protein is 0, or up to 8 mg/100 mL. The number of WBCs is 0 to 4 per low-power field, and casts should be 0 in a normal urinalysis.

DIF: A REF: 1140 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

20. The client is experiencing urinary retention, and the health care provider is contacted. The nurse anticipates a medication that will be ordered to promote emptying of the bladder is:

1.

Oxybutynin chloride (Ditropan)

2.

Bethanechol (Urecholine)

3.

Propantheline (Pro-Banthine)

4.

Nystatin (Mycostatin)

ANS: 2

Cholinergic drugs, such as bethanechol (Urecholine), increase contraction of the bladder and improve emptying. Bethanechol stimulates parasympathetic nerves to increase bladder wall contraction and relax the sphincter. Oxybutynin chloride (Ditropan) is an anticholinergic drug that depresses the neurotransmitter acetylcholine (which normally stimulates the bladder), and thus reduces incontinence. Propantheline (Pro-Banthine) is an anticholinergic drug that depresses the neurotransmitter acetylcholine (which normally stimulates the bladder), and thus reduces incontinence. Nystatin (Mycostatin) is an antifungal agent.

DIF: A REF: 1133 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

21. Which of the following actions by the nurse would indicate the need for remedial education in the removal of an indwelling catheter?

1.

Draping the female client between the thighs

2.

Obtaining a specimen before removal

3.

Cutting the catheter to deflate the balloon

4.

Checking the clients output for 24 hours after removal

ANS: 3

The nurse should not cut the catheter to deflate the balloon. The nurse inserts an empty, sterile syringe into the injection port. The nurse slowly withdraws all of the solution to deflate the balloon totally. The nurse then pulls the catheter out smoothly and slowly. The nurse positions the client in the same position as during catheterization. The nurse places a towel between a female clients thighs or over a male clients thighs. Some institutions recommend collecting a sterile urine specimen before removal of the catheter or sending the catheter tip for culture and sensitivity tests. The nurse should assess the clients urinary function by noting the first voiding after catheter removal and documenting the time.

DIF: A REF: 1165 OBJ: Comprehension

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

22. A condom catheter is to be used for an adult male client in the extended care facility. In the application of the condom catheter, the nurse employs appropriate technique when:

1.

Using sterile gloves

2.

Wrapping the adhesive tape securely around the base of the penis

3.

Leaving a 1- to 2-inch space between the tip of the penis and the end of the catheter

4.

Taping the tubing tightly to the thigh and attaching the drainage bag to the bed frame

ANS: 3

A 1- to 2-inch space should be left between the tip of the penis and the end of the catheter. Nonsterile gloves are worn to apply a condom catheter. Standard adhesive tape should never be used to secure a condom catheter because it does not expand with change in penis size and is painful to remove. The tubing of a condom catheter is not taped tightly to the thigh. The drainage bag is attached to the lower bed frame.

DIF: A REF: 1169 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

23. Urinary elimination may be altered with different pathophysiological conditions. For the client with diabetes mellitus, the nurse anticipates that an initial urinary sign or symptom will be:

1.

Urgency

2.

Dysuria

3.

Hematuria

4.

Polyuria

ANS: 4

An initial urinary symptom of diabetes mellitus is polyuria. Urgency is not a symptom of diabetes mellitus. Urgency may be caused by a full bladder, bladder irritation from infection, incompetent urethral sphincter, or psychological stress. Dysuria is not a symptom of diabetes mellitus. Dysuria may be caused by bladder inflammation, trauma, or inflammation of the urethral sphincter. Hematuria is not a symptom of diabetes mellitus. Hematuria may be a symptom of neoplasms of the bladder or kidney, glomerular disease, infection of the kidney or bladder, trauma to urinary structures, calculi, or bleeding disorders.

DIF: A REF: 1138 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

24. The nurse is assessing a client admitted with complaints related to chronic kidney dysfunction. The nurse recognizes that this client is most likely to present with which of the resulting symptoms?

1.

Anemia

2.

Hypotension

3.

Diabetes mellitus

4.

Clinical depression

ANS: 1

Clients with chronic alterations in kidney function cannot produce sufficient quantities of the hormone erythropoietin; therefore they are prone to anemia. Diabetes mellitus may be a cause of the renal dysfunction, and the client may or may not be depressed. Hypertension, not hypotension, is a typical outcome of kidney dysfunction.

DIF: C REF: 1138 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

25. Which of the following statements made by a client experiencing chronic kidney dysfunction reflects the best understanding of the most common physiological effect this disorder can have on the body?

1.

Im tested regularly for anemia.

2.

My diet is restricted because of this problem.

3.

Diabetes runs in my family, so I get tested regularly.

4.

I can get really depressed if I think about this too much.

ANS: 1

Clients with chronic alterations in kidney function cannot produce sufficient quantities of the hormone erythropoietin; therefore they are prone to anemia. The remaining options deal with nonphysiological events or conditions that are more causes of the dysfunction, not effects.

DIF: C REF: 1130 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

26. Which of the following clients is at greatest risk for developing a renal infection?

1.

A 27-year-old male

2.

A 16-year-old male

3.

A 9-year-old female

4.

A 45-year-old female

ANS: 3

The short length of the urethra predisposes women and girls to infection. It is easy for bacteria to enter the urethra from the perineal area. The 9-year-old female has the shortest urethra and so has the greatest risk.

DIF: A REF: 1131 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

27. Which of the following clients will most benefit from client/parent education regarding the prevention of renal infections via proper hygiene habits?

1.

Males ages 35 to 65

2.

Males ages 3 to 16

3.

Females ages 3 to 12

4.

Females ages 20 to 50

ANS: 3

The 3- to 12-year-old female has the shortest urethra and so has the greatest need. The short length of the urethra predisposes women and girls to infection. It is easy for bacteria to enter the urethra from the perineal area.

DIF: C REF: 1131 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

28. The nurse is interviewing a client with a history of benign prostatic hypertrophy (BPH). In light of this diagnosis, the nurse should include information regarding which of the following in order to assess the chronic effects of this renal disorder?

1.

Number of times he usually urinates in a 24-hour period

2.

What medications he is currently taking for the condition

3.

The results of his latest prostate-specific antigen (PSA) testing

4.

Whether he usually experiences a complete emptying of his bladder

ANS: 4

If a chronic obstruction such as prostate enlargement hinders bladder emptying, over time the micturition reflex changes, causing bladder overactivity, and can cause the bladder to not completely empty. The remaining options focus on the impact the condition has on daily living and the monitoring necessary to determine the presence of prostate cancer.

DIF: C REF: 1138 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

29. Which of the following statements made by a client with benign prostatic hypertrophy (BPH) during an admissions interview reflects the best understanding of the long-term effects of this condition?

1.

I usually get up 3 to 4 times a night to urinate.

2.

My health care provider prescribed some medication that has helped.

3.

At least I can usually empty my bladder; I really hate that feeling of being full.

4.

The prostate specific antigen (PSA) results have stayed stable for the last 3 tests.

ANS: 3

If a chronic obstruction such as prostate enlargement hinders bladder emptying, over time the micturition reflex changes, causing bladder overactivity, and can cause the bladder to not completely empty. The remaining options focus on the impact the condition has on daily living and the monitoring of the client for prostate cancer.

DIF: C REF: 1138 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

30. The nurse realizes that a postsurgical client who underwent a left knee replacement is most likely to experience which of the following urinary complications?

1.

Dysuria

2.

Bladder spasms

3.

A bladder infection

4.

Burning on urination

ANS: 1

Medications including anesthesia interfere with both the production and the characteristics of urine and affect the act of urination. Difficulty with urination is a common complication of general anesthesia. The remaining options are not directly connected to postsurgical complications.

DIF: C REF: 1138 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

31. The nurse recognizes that a client recovering from anesthesia required for surgical repair of a fractured ulna is likely to experience difficulty urinating primarily because of:

1.

The impaired cognitive state the client will experience as the effects of the anesthesia wear off

2.

The decreased volume of orally ingested fluids before, during, and after the surgical procedure

3.

The length of time the client was under the effects of general anesthesia required for the surgical procedure

4.

The effects of the anesthetic on the nerves and muscles controlling the relaxation of the urinary bladder

ANS: 4

Medications, including anesthesia, interfere with both the production and the characteristics of urine and affect the act of urination. The remaining options may affect urination but not to the extent of the anesthetic effects.

DIF: C REF: 1138 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

32. A 70-year-old client is discussing his recent difficulty in initiating his flow of urine while on a cross-country bus tour with a senior citizens group. Which of the following assessment questions is directed toward the most likely cause of the problem?

1.

Did the bus stop frequently so you could get up and walk around?

2.

Did you drink plenty of water while you were on the trip?

3.

Do you find using public restrooms unsettling?

4.

Do you have any chronic urinary problems?

ANS: 3

Attempting to void in a public restroom sometimes results in a temporary inability to void. Although the remaining options may affect urination, this situation strongly suggests an emotional cause.

DIF: C REF: 1132 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

33. Which of the following nursing interventions is most specific for a client being monitored for possible urinary retention?

1.

Measuring urine output with each urination

2.

Monitoring the color and clarity of urine with each voiding

3.

Collecting a urine sample for a culture and sensitivity test

4.

Asking the cognizant client to report each time he or she urinates

ANS: 4

With retention the client may void small amounts of urine 2 or 3 times an hour with no real relief of discomfort or may continually dribble urine. Be aware of the volume and frequency of voiding to assess this condition in the client. The alert, oriented client can be asked to notify the nurse each time micturition occurs. The remaining options are more generalized or specific for a urinary tract infection.

DIF: C REF: 1138 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

34. The nurse is caring for an older adult who is recovering from hip replacement surgery. The client shares with the nurse that he has been using the urinal a lot but I feel like my bladder isnt empty. Which of the following statements by the nurse shows the best understanding of the appropriate initial intervention for this particular client?

1.

Ill call your primary care provider and let her know you are having this problem.

2.

I have the ancillary personnel measure your output, so please dont empty your urinal yourself.

3.

Im going to ask that you please use your call bell and notify me or the ancillary staff each time you void.

4.

I suggest that we try limiting the amount of fluids you are drinking for a few hours and see if that helps.

ANS: 3

With retention the client may void small amounts of urine 2 or 3 times an hour with no real relief of discomfort or may continually dribble urine. Be aware of the volume and frequency of voiding to assess this condition in the client. The alert, oriented client can be asked to notify the nurse each time micturition occurs. The notification of the primary care provider is not the initial intervention. Although measuring the urine output is not inappropriate, it is not specific to this clients complaint. Restricting fluids is neither appropriate nor likely to affect the problem.

DIF: C REF: 1138 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

35. The nurse is discussing signs and symptoms of both upper and lower urinary tract infections with a client who has a history of both. Which of the following statements by the client reflects the best understanding of the differing symptomatology?

1.

When I get cloudy urine, I figure I have an infection.

2.

Burning when I urinate is usually the first symptom I notice.

3.

I have a big problem when I feel like I have the flu but with back pain too.

4.

When I see blood in my urine, I know I need to call my health care provider.

ANS: 3

Clients with lower UTIs have pain or burning during urination (dysuria) as urine flows over inflamed tissues. Fever, chills, nausea, vomiting, and malaise develop as the infection worsens. An irritated bladder (cystitis) causes a frequent and urgent sensation of the need to void. Irritation to bladder and urethral mucosa results in blood-tinged urine (hematuria). The urine appears concentrated and cloudy because of the presence of WBCs or bacteria. If infection spreads to the upper urinary tract (kidneyspyelonephritis, a serious renal condition), flank pain, tenderness, fever, and chills are common. The remaining options identify general symptoms that are not condition specific.

DIF: C REF: 1134 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

36. The nurse is discussing urinary elimination alterations with a group of middle-age adults. The nurse appropriately shares with the group that whereas men experience urinary frequency as a result of prostate enlargement, the female:

1.

Is more affected if she has experienced multiple pregnancies

2.

Does not usually experience urinary problems until much later in life

3.

Experiences an increased risk for urinary tract infections related to menopause

4.

Appears to have less risk for kidney infections because of gradually declining estrogen levels

ANS: 3

Aging often impairs micturition. In the male, prostate enlargement usually begins during the 40s and continues throughout life, resulting in urinary frequency and possible urinary retention. In women, changes in the urethral mucosa associated with loss of estrogen during and after menopause contribute to increased susceptibility to UTIs. Although pregnancies may affect urinary continence, decreased estrogen levels do not protect against kidney infections.

DIF: C REF: 1134 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

37. The nurse is caring for a 19-year-old male client with a fractured left femur whose leg was pinned 36 hours ago and is now in traction. Which of the following stressors is mostly likely the cause of this clients difficulty related to starting urine flow?

1.

Pain related to the fracture and its repair

2.

Anxiety regarding the serious nature of the injury

3.

The inability to stand in order to facilitate urination

4.

Poor fluid intake in the accident and ensuing surgery

ANS: 3

Some men who cannot stand to urinate become overly distressed. Although the other options may have some effect, the primary cause is most likely the emotional stress of not being able to assume the usual position for male urination.

DIF: C REF: 1151 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

38. Which of the following statements made by an older adult with a history of urinary tract infections shows the best understanding of interventions that minimize the risk for developing such infections?

1.

I drink 8 ounces of cranberry juice a day to discourage bacterial growth in my bladder.

2.

Whenever I feel an infection coming on, I immediately call my health care provider.

3.

I told the nurses I didnt want a urinary catheter unless I absolutely had to have one.

4.

Whenever I can, I avoid drinking after 8 PM because I usually go to bed about 11 PM.

ANS: 1

Make fluids such as cranberry juice available as part of the clients fluid intake. Cranberry juice discourages bacterial adherence to the bladder wall. The remaining options either have less impact on a daily basis or are more related to early detection rather than prevention.

DIF: C REF: 1150 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

39. The nurse is caring for a 23-year-old male client who is in the ICU with second and third degree burns over 40 percent of his body. One of the first symptoms that the client is having organ failure is that the urine output is less than:

1.

30 mL/hour

2.

40 mL/hour

3.

50 mL/hour

4.

60 mL/hour

ANS: 1

An output of less than 30 mL/hr indicates possible renal alterations.

DIF: B REF: 1134 OBJ: Application

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

40. The nurse knows that which of the following clients is most at risk for a bone fracture:

1.

44-year-old female with rheumatoid arthritis

2.

64-year-old male with Cushings disease

3.

53-year-old female with chronic alterations in renal function

4.

60-year-old male with cirrhosis of the liver

ANS: 2

The kidneys affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form. Clients with chronic alterations in kidney function do not make sufficient amounts of the active vitamin D. They are prone to develop renal bone disease resulting from the demineralization of bone caused by impaired calcium absorption.

DIF: A REF: 1132 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

41. A 33-year-old female client in her first trimester of pregnancy complains to the nurse on her prenatal visit that she is needs to urinate more frequently and is concerned about having a urinary tract infection. Which of the following statements would be most appropriate for the nurse to make?

1.

Are you having any burning or pain when you urinate?

2.

Your uterus is pushing up against your bladder which causes you to have to go more frequently

3.

Later in your pregnancy as the baby gets bigger it will be a lot worse

4.

It is normal for you to have to urinate more frequently because you are eliminating for two now

ANS: 1

In a pregnant woman the developing fetus pushes against the bladder, reducing the bladders capacity and causing a feeling of fullness. This effect is more likely to occur in the first and third trimesters. Since the client expressed concern regarding a UTI, the nurse should make further assessments to explore that possibility.

DIF: A REF: 1134 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

42. The nurse is caring for a 56-year-old female client with renal failure who regularly undergoes peritoneal dialysis. The nurse understands that this client is most at risk for:

1.

Pulmonary embolism

2.

Electrolyte imbalances

3.

Polyuria

4.

Urinary incontinence

ANS: 2

Peritoneal dialysis is an indirect method of cleansing the blood of waste products using osmosis and diffusion with the peritoneum functioning as a semipermeable membrane. This method removes excess fluid and waste products from the bloodstream when a sterile electrolyte solution (dialysate) is instilled into the peritoneal cavity by gravity via a surgically placed catheter. The dialysate remains in the cavity for a prescribed time interval and then is drained out by gravity, taking accumulated wastes and excess fluid and electrolytes with it. This places the client at risk for electrolyte imbalances.

DIF: A REF: 1138 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

43. A 46-year-old client has had kidney disease for the past 10 years. His kidneys are no longer functioning. The nurse knows that which of the following offers the client the potential for restoration of normal kidney function?

1.

Lasix therapy

2.

Hemodialysis

3.

Peritoneal dialysis

4.

Kidney transplant

ANS: 4

Unlike the other treatments, successful organ transplantation offers the client the potential for restoration of normal kidney function.

DIF: C REF: 1130 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

44. A 45-year-old female client has been hospitalized for severe abdominal pain. The health care provider has ordered a PCA pump for the client to help control the pain. It has been determined that the pain is due to cholelithiasis and the client is scheduled for a cholecystectomy later that day. The client returns to the unit postoperatively with a Foley catheter anchored. The nurse notes that the clients urine output has decreased. The nurse knows that this is most likely due to:

1.

Stress response

2.

Preoperative NPO status

3.

Kidney failure

4.

Post-operative urinary retention

ANS: 1

The stress response releases an increased amount of ADH, which increases water reabsorption. Stress also elevates the level of aldosterone, causing retention of sodium and water. Both of these substances reduce urine output in an effort to maintain circulatory fluid volume. Although the client was NPO postoperatively, she had a pain pump, which indicates that she had a running IV with fluids. It is not indicated that the client had kidney failure, and since the client had an anchored urinary catheter, she would not have urinary retention.

DIF: A REF: 1131 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

45. A 73-year-old female client with Parkinsons syndrome was prescribed levodopa when other therapies had failed. The client is alarmed that her urine has become dark brown and is concern. The nurse explains to the client that one of the side effects of this medication is that it may cause:

1.

Her urine to become dark brown or black

2.

Heart failure

3.

Kidney failure

4.

Hair loss

ANS: 1

Some medications change the color of urine. Phenazopyridine (Pyridium) colors the urine a bright orange to rust; amitriptyline causes a green or blue discoloration, whereas levodopa discolors the urine to brown or black.

DIF: C REF: 1134 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

46. A 34-year-old diabetic female client had a spontaneous vaginal birth of a 37-week 6.2 kg infant. The nurse caring for the client post-partum understands that due to the traumatic birth the client is at increased risk for:

1.

Acute urinary retention

2.

Hematuria

3.

Kidney failure

4.

Enuresis

ANS: 1

In acute retention key signs are bladder distention and absence of urine output over several hours. The client under the influence of anesthetics or analgesics often feels only pressure, but the alert client has severe pain as the bladder distends beyond its normal capacity. In severe urinary retention the bladder holds as much as 2000 to 3000 mL of urine. Retention occurs as a result of urethral obstruction, surgical or childbirth trauma, alterations in motor and sensory innervation of the bladder, medication side effects, or anxiety.

DIF: C REF: 1132 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

47. A 46-year-old male client with chronic renal problems is in the hospital for a nephrostomy. The nurse understands that this is the surgical insertion of a tube that will drain urine from the clients:

1.

Bladder

2.

Urethra

3.

Ureters

4.

Renal pelvis

ANS: 4

Some clients have a need for urinary drainage directly from one or both kidneys. In this case a tube placed directly into the renal pelvis. This procedure is called a nephrostomy.

DIF: A REF: 1132 OBJ: Knowledge

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

MULTIPLE RESPONSE

1. Which of the following clients presents with an increased risk for urinary incontinence? (Select all that apply.)

1.

The 74-year-old diagnosed with parkinsonism 5 years ago

2.

The 25-year-old with Crohns disease diagnosed 4 years ago

3.

The 62-year-old Alzheimers disease client diagnosed 8 years ago

4.

The 34-year-old mother of two diagnosed with multiple sclerosis 8 years ago

5.

The 73-year-old diagnosed with benign prostatic hyperplasia (BPH) 6 years ago

6.

The 69-year-old client diagnosed with type 2 diabetes 9 years ago

ANS: 1, 3, 4, 5, 6

Many diseases and conditions affect the ability to micturate. Diabetes mellitus and multiple sclerosis cause changes in nerve functions that can lead to possible loss of bladder tone, reduced sensation of bladder fullness, or inability to inhibit bladder contractions. Older men often suffer from BPH, which makes them prone to urinary retention and incontinence. Some clients with cognitive impairments, such as Alzheimers disease, lose the ability to sense a full bladder or are unable to recall the procedure for voiding. Diseases that slow or hinder physical activity interfere with the ability to void. Degenerative joint disease and parkinsonism are examples of conditions that make it difficult to reach and use toilet facilities. Crohns disease is gastrointestinal in nature and does not directly affect micturition.

DIF: C REF: 1133 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

2. The nurse is caring for a client with type 1 diabetes who has been diagnosed with end-stage renal disease (ESRD). The nurse regularly assesses the client for which of the following? (Select all that apply.)

1.

Nausea

2.

Polyuria

3.

Lethargy

4.

Vomiting

5.

Confusion

6.

Headache

ANS: 1, 3, 4, 5, 6

Diseases that cause irreversible damage to kidney tissue result in end-stage renal disease (ESRD). Eventually the client has symptoms resulting from uremic syndrome. An increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, oliguria, nausea, vomiting, headache, drowsiness, coma, and convulsions characterize this syndrome.

DIF: A REF: 1133 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

3. Which of the following symptomatology is reflective of a lower urinary tract infection? (Select all that apply.)

1.

Chills and fever

2.

Nausea and vomiting

3.

Frequency or urgency

4.

Cloudy or blood-tinged urine

5.

Pelvic tenderness or flank pain

6.

Burning or pain when voiding

ANS: 1, 2, 3, 4, 6

Clients with lower UTIs have pain or burning during urination (dysuria) as urine flows over inflamed tissues. Fever, chills, nausea, vomiting, and malaise develop as the infection worsens. An irritated bladder (cystitis) causes a frequent and urgent sensation of the need to void. Irritation to bladder and urethral mucosa results in blood-tinged urine (hematuria). The urine appears concentrated and cloudy because of the presence of white blood cells (WBCs) or bacteria. If infection spreads to the upper urinary tract (kidneyspyelonephritis, a serious renal condition), flank pain, tenderness, fever, and chills are common.

DIF: A REF: 1133 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Basic Care and Comfort/Elimination

4. The nurse is discussing a middle-age adult male clients report of nocturia. The client has diabetes that is managed with diet and exercise as well as hypertension that is currently well-controlled with medication. The nurse should include which of the following as possible causes for his frequent urination at night? (Select all that apply.)

1.

An enlarged prostate gland

2.

Poorly controlled blood glucose

3.

Drinking a cup of tea before bed

4.

Possible side effect of his medication

5.

Taking his diuretic too close to bedtime

6.

Consuming too many liquids during the day

ANS: 1, 2, 3, 5

Excessive fluid intake before bed (especially coffee or alcohol), renal disease, the aging process, prostate enlargement, poorly controlled diabetes, and diuretic medication therapy scheduled late in the day can cause nocturia. If taken appropriately, his medications are not likely a cause.

DIF: C REF: 1135 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation Physiological Integrity/Basic Care and Comfort/Elimination

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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