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A nurse is caring for a client who has just undergone surgery to create an ileal
conduit for urinary elimination via a stoma. Which fact about this procedure
should the nurse mention to the client?
This urinary diversion is only temporary.
The client will need to change the urinary pouch every 4 hours.
The client will have to wear an external appliance to collect urine.
Urination can be voluntarily controlled after the stoma heals from the initial
surgery. - correct answers The client will have to wear an external appliance
to collect urine.
Explanation:
An ileal conduit involves a surgical resection of the small intestine, with
transplantation of the ureters to the isolated segment of small bowel. Such
diversions are usually permanent, and the client wears an external appliance
to collect the urine because urine elimination from the stoma cannot be
controlled voluntarily. Appliances are usually changed every 3 to 7 days,
although they could be changed more often.
When collecting a urine sample from a client for examination, the nurse notes
that the sample appears reddish-brown in color. What could cause this
variation in color of the urine?
dehydration
infection
stasis
blood - correct answers blood
Explanation:
,A reddish-brown urine sample is indicative of the presence of blood. The urine
appears dark amber in color due to dehydration. Infection and stasis would
cause the urine to appear cloudy.
A nurse is caring for a client with a hemodialysis access site. Which action
should the nurse take?
Auscultate over the access site with the bell of a stethoscope, listening for a
bruit or vibration.
Administer an IV on the arm high above the access site.
Perform venipuncture below the access site to obtain a blood sample for
laboratory testing.
Measure the client's blood pressure on the arm above the access site. -
correct answers Auscultate over the access site with the bell of a stethoscope,
listening for a bruit or vibration.
Explanation:
The nurse should auscultate over the hemodialysis access site with the bell of
a stethoscope, listening for a bruit or vibration, to assess the patency of the
access. The nurse should not measure the client's blood pressure, perform a
venipuncture, or start an IV on the access arm, as doing so could lead to
infection or clotting of the graft or fistula.
An older adult female client tells the nurse, "Whenever I sneeze or cough, I
urinate a little bit. It's very embarrassing." The nurse interprets the client's
statement as indicating which type of incontinence?
Urge
Stress
Overflow
Functional - correct answers Stress
Explanation:
,Stress incontinence is caused by pelvic floor muscle weakness or urethral
hypermobility.
Urge incontinence is caused by an overactive detrusor muscle causing
involuntary bladder contraction.
Overflow incontinence occurs when the bladder muscle distends and urine is
forced out.
Functional incontinence occurs when a physical or psychological impairment
impedes continence despite a competent urinary system.
A client is prescribed an indwelling urinary catheter for 2 days prior to surgery.
Which action should the nurse take to decrease the occurrence of health care-
associated infection (HAI) for this client?
Encourage fluid intake.
Maintain the urinary catheter until discharge.
Request a straight catheter from the health care provider.
Irrigate the catheter twice per day. - correct answers Encourage fluid intake.
Explanation:
Urinary catheterization is the most common cause of HAI. The catheter should
be inserted for the shortest possible duration. Fluids should be encouraged.
Intermittent catherization and too frequent catheter irrigation can increase the
risk of infection.
A nurse drains the bladder of a client by inserting a catheter for 5 minutes.
What type of catheter would the nurse use in this instance?
indwelling urethral catheter
intermittent urethral catheter
Foley catheter
retention catheter - correct answers intermittent urethral catheter
, Explanation:
An intermittent urethral catheter (straight catheter) is a catheter inserted
through the urethra into the bladder to drain urine for a short period of time (5
to 10 minutes). With an indwelling urethral catheter (retention or Foley
catheters), a catheter (tube) is inserted through the urethra into the bladder for
continuous drainage of urine; a balloon is then inflated to ensure that the
catheter remains in the bladder once it is inserted.
The nurse is caring for a client who has been experiencing difficulty voiding in
the eight hours since her vaginal birth. What information should be provided to
the client?
The birth can cause perineal swelling.
A neurogenic bladder results from local anesthesia
A urinary tract infection can result from the birth process
Catheterization is likely necessary for five to seven days - correct answers
The birth can cause perineal swelling.
Explanation:
Trauma from vaginal birth causes swelling in the perineal area, which can
obstruct the flow of urine and cause urinary retention during the early
postpartum period. The effects of anesthesia do not constitute a neurogenic
bladder. Catheterization may be necessary in the short term, but 5 to 7 days
would normally be excessive and create a risk for infection. Birth does not
normally cause a UTI, whose effects would not evident at this early stage
postpartum.
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The nurse is caring for a client with weakness who is ambulatory but tires
easily. Which method for urinary elimination does the nurse recommend?
fracture pan
bedside commode