Chapter 045

Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 45: Urinary Elimination 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
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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 4: !rinary Elimination !#T$P#E C%$CE 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 diapers2.Catheterize the client3.Administer Urecholine.Teach !egel e ercisesA#$:%elvic floor e ercises& also 'no(n as !egel e ercises& improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups. These e ercises have demonstrated effectiveness in treating stress incontinence& overactive bladders& and mi ed causes of urinary continence. The client is oriented and therefore could be taught !egel e ercises to improve pelvic floor muscle tone. Applying adult diapers does not improve the client)s problem of incontinence and places the client at ris' for s'in  brea'do(n. *ecause bladder catheterization carries the ris' for urinary tract infection +UT,-& it is preferable to rely on other measures for management of incontinence. The nurse can support the use of !egel e ercises as an ine pensive nonpharmacological intervention to reduce the client)s stress incontinence. *ethanechol +Urecholine- stimulates the parasympathetic nervous system to promote complete bladder emptying and is primarily used to treat urinary retention and possible overflo( incontinence.  #onpharmacological approaches should be attempted before pharmacological approachesare ta'en.,/:A0/:11*4:ComprehensionT%:#ursing %rocess: %lanning5$C:#C678 test plan designation: %hysiological ,ntegrity9*asic Care and Comfort9limination2.hich of the follo(ing statements should the nurse use to instruct the nursing assistant caring for a client (ith an ind(elling urinary catheter;1.mpty the drainage bag at least every  hours.2.Clean up the length of the catheter to the perineum.3.Use clean techni<ue to obtain a specimen for culture and sensitivity..%lace the drainage bag on the client)s lap (hile transporting the client to testing.A#$:1 5osby items and derived items = 2>>?& 2>>@ by 5osby& ,nc.& an affiliate of lsevier ,nc.  Test *an' The urinary drainage bag should be emptied at least every  hours. ,f large outputs are noted& more fre<uent emptying (ill be re<uired. The perineum should be cleansed and then do(n the catheter for a length of appro imately 1> cm + inches-. nly use sterile techni<ue to collect specimens from a closed drainage system. Avoid raising the drainage  bag above the level of the bladder. ,f it becomes necessary to raise the bag during transfer of the client to a bed or stretcher& clamp the tubing or empty the tubing contents to the drainage bag first. The drainage bag can be attached to the (heelchair belo( the level of the client)s bladder for transport. ,t should not be placed on the client)s lap.,/:A0/:11*4:ComprehensionT%:#ursing %rocess: ,mplementation5$C:#C678 test plan designation: %hysiological ,ntegrity9*asic Care and Comfort9limination3.The nurse suspects that the client has a bladder infection based on the clientBs e hibiting an early sign or symptom such as:1.Chills2.ematuria3./lan' pain.,ncontinenceA#$:2,rritation to the bladder and urethral mucosa results in bloodDtinged urine +hematuria-. ematuria is a sign of a bladder infection. Chills are a more systemic symptom associated (ith pyelonephritis. /lan' pain is a more systemic symptom associated (ith  pyelonephritis. ,ncontinence is not a symptom of a bladder infection.,/:A0/:113*4:ComprehensionT%:#ursing %rocess: Assessment5$C:#C678 test plan designation: %hysiological ,ntegrity9*asic Care and Comfort9limination.hen obtaining a sterile urine specimen from an ind(elling urinary catheter the nurse should:1.isconnect the catheter from the drainage tubing2.ithdra( urine from a urinometer 3.pen the drainage bag and removing urine.Use a needle to (ithdra( urine from the catheter portA#$: 5osby items and derived items = 2>>?& 2>>@ by 5osby& ,nc.& an affiliate of lsevier ,nc. @D2  Test *an' A sterile specimen can be obtained through the special port found on the side of the ind(elling catheter. The nurse clamps the tubing belo( the port& allo(ing fresh& uncontaminated urine to collect in the tube. After the nurse (ipes the port (ith an antimicrobial s(ab& a sterile syringe needle is inserted& and at least 3 to @ m6 of urine is (ithdra(n. Using sterile techni<ue& the nurse transfers the urine to a sterile container. Thecatheter should not be disconnected from the drainage tubing. The system should remain a closed system to prevent infection. A urinometer is a device used to determine the specific gravity of urine. ,t is not a sterile device and should not be used for obtaining a sterile urine specimen. Urine should not be obtained from a drainage bag for a specimen&  because the urine (ould not be fresh and (ould be contaminated from microorganisms inthe drainage bag.,/:A0/:11>*4:ComprehensionT%:#ursing %rocess: ,mplementation5$C:#C678 test plan designation: %hysiological ,ntegrity9*asic Care and Comfort9limination@.,mmediately after an intravenous pyelogram +,E%- the nurse should observe the client for (hich of the follo(ing;1.,nfection in the urinary bladder 2.An allergic reaction to the contrast material3.Urinary suppression caused by inFury to 'idney tissues.,ncontinence as a result of paralysis of the urinary sphincter A#$:2After an ,E% the nurse should encourage fluid inta'e to dilute and flush dye from the client and observe the client for late symptoms of allergy +e.g.& rash-. There is no increased ris' for infection of the urinary bladder from an ,E%. This (ould be more li'ely(ith an invasive procedure& such as an endoscopy +cystoscopy-. An ,E% should not inFuretissues of the 'idney or cause paralysis of the urinary sphincter.,/:A0/:11@*4:ComprehensionT%:#ursing %rocess: Assessment5$C:#C678 test plan designation: %hysiological ,ntegrity9*asic Care and Comfort9limination.A client (ith an e cessive alcohol inta'e has a reduced amount of antidiuretic hormone +A-. The nurse anticipates the client (ill e hibit:1.ematuria2.An increased blood pressure3.ry mucous membranes.A lo( serum sodium level A#$:3 5osby items and derived items = 2>>?& 2>>@ by 5osby& ,nc.& an affiliate of lsevier ,nc. @D3  Test *an' Alcohol inhibits the release of A& resulting in increased (ater loss in urine. The client may sho( signs of decreased fluid volume +dehydration-& including dry mucous membranes. The effects of e cessive alcohol inta'e and reduced antidiuretic hormone (ill not cause hematuria. aving decreased levels of antidiuretic hormone (ill lead to increased urine production. The client may e hibit a decreased blood pressure resulting from decreased fluid volume and an increased serum sodium level (ith dehydration.,/:A0/:1133*4:ComprehensionT%:#ursing %rocess: Assessment5$C:#C678 test plan designation: %hysiological ,ntegrity9*asic Care and Comfort9liminationG.A client is going to have a cystoscopy. hich of the follo(ing reflects the correct information that should be taught before the procedure;1.HAre you allergic to iodine;I2.HThere (ill be no need to have a special consent form.I3.HJou (ill need to have fluids restricted the evening before the cystoscopy.I.HJou (ill probably be given sedatives before the procedure.IA#$:Although this procedure may be accomplished using local anesthesia& it is more commonly performed using general anesthesia or conscious sedation to avoid unnecessary an iety and trauma for the client. A cystoscopy involves direct visualization.  #o contrast dye is usedK therefore the nurse does not need to as' if the client is allergic to iodine. A signed consent form is obtained. /luids are not restricted before or after the  procedure. The flushing action helps remove bacteria from the urethra.,/:A0/:11*4:ComprehensionT%:#ursing %rocess: ,mplementation5$C:#C678 test plan designation: %hysiological ,ntegrity9*asic Care and Comfort9limination.A postpartum client has been unable to void since her delivery of her baby this morning. hich of the follo(ing nursing measures (ould be beneficial for the client initially;1.,ncrease fluid inta'e to 3@>> m6.2.,nsert ind(elling /oley catheter.3.0inse the perineum (ith (arm (ater..Apply firm pressure over the bladder.A#$:3 5osby items and derived items = 2>>?& 2>>@ by 5osby& ,nc.& an affiliate of lsevier ,nc. @D
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