ATI Urinary Elimination - practice
assessment
***(?) A nurse is discussing indications for urinary catheterization with a
newly licensed nurse. Which of the following indications should the nurse
include? (Select all that apply.)
a. Relief of urinary retention
b. Convenience for the nursing staff or the client's family
c. Measurement of residual urine after urination
d. Routine acquisition of a urine specimen
e. An open perineal wound - -Relief of urinary retention
Measurement of residual urine after urination
An open perineal wound
Valid indications for urinary catheterization include urinary retention,
bladder distention, management of urinary elimination for clients who
have spinal cord injuries, and prevention of urethral obstruction from
blood clots following genitourinary surgery.
- A charge nurse is observing a newly-licensed nurse insert an indwelling
urinary catheter for a male client. Which of the following actions by the
newly-licensed nurse requires intervention by the charge nurse?
a. Lubricates the first 2.5 to 5 cm (2 in) of the catheter.
b. Dons sterile gloves before cleaning the client's meatus.
c. Secures the tubing to the client's upper thigh.
d. Pulls gently on the catheter to check for resistance after inflating the
balloon. - -Lubricates the first 2.5 to 5 cm (2 in) of the catheter.
The nurse should lubricate the first 2.5 to 5 cm (1 to 2 in) of the catheter
when inserting a catheter into a female client. The nurse should lubricate
the first 15 to 17.5 cm (6 to 7 in) when inserting a catheter into a male
client. cleaning the client's meatus.
- A charge nurse is observing a nurse insert an indwelling urinary
catheter into a female client. For which of the following actions by the
nurse should the charge nurse intervene?
a. The nurse separates the client's labia with her dominant hand.
b. The nurse coats the indwelling urinary catheter with lubricant.
c. The nurse provides perineal care prior to inserting the urinary catheter.
d. The nurse applies the sterile drape prior to inserting the urinary
catheter. - -The nurse separates the client's labia with her dominant hand.
, The nurse should use her non-dominant hand to separate the labia, or to
hold the penis in male clients. The dominant hand is the hand that should
handle the catheter during insertion and when filling the balloon. If the
nurse separated the labia with her dominant hand, it would be more
difficult to insert the catheter in a sterile environment and could result in
introduction of bacteria into the urinary tract.
- A client who has an elevated BUN is most likely to have a
manifestation of
a. A client who reports painful urination of a
b. A client who reports urinary frequency
c. A client who has glucose in his urine - -A client who reports urinary
frequency
Voiding a small amount of urine (less than 100 mL) frequently (2 to 3
times per hr), and dribbling of urine are manifestations of urinary
retention.
- A nurse assessing a client notes that the client has a constant leakage
of small amounts of urine and a bladder that is distended and palpable.
The nurse should associate these findings with which of the following
types of urinary incontinence?
a. Stress incontinence
b. Urge incontinence
c. Overflow incontinence
d. Reflex incontinence - -Overflow incontinence
These findings are associated with overflow incontinence, which occurs
when the pressure of urine in an overfull bladder overcomes sphincter
control.
- A nurse in a clinic is assessing a client who has a new diagnosis of
interstitial cystitis. The nurse should expect which of the following?
a. Negative urine culture
b. Denies urgency
c. Denies pain with urination
d. Fever - -Negative urine culture
A laboratory finding of a negative urine culture is consistent with a
diagnosis of interstitial cystitis since it is a non-infectious process.
- A nurse in a long-term care facility is caring for an older adult client
who has dementia and begins to have frequent episodes of urinary
incontinence. After the provider determines no medical cause for the
client's incontinence, which of the following interventions should the nurse
initiate to manage this behavior?
assessment
***(?) A nurse is discussing indications for urinary catheterization with a
newly licensed nurse. Which of the following indications should the nurse
include? (Select all that apply.)
a. Relief of urinary retention
b. Convenience for the nursing staff or the client's family
c. Measurement of residual urine after urination
d. Routine acquisition of a urine specimen
e. An open perineal wound - -Relief of urinary retention
Measurement of residual urine after urination
An open perineal wound
Valid indications for urinary catheterization include urinary retention,
bladder distention, management of urinary elimination for clients who
have spinal cord injuries, and prevention of urethral obstruction from
blood clots following genitourinary surgery.
- A charge nurse is observing a newly-licensed nurse insert an indwelling
urinary catheter for a male client. Which of the following actions by the
newly-licensed nurse requires intervention by the charge nurse?
a. Lubricates the first 2.5 to 5 cm (2 in) of the catheter.
b. Dons sterile gloves before cleaning the client's meatus.
c. Secures the tubing to the client's upper thigh.
d. Pulls gently on the catheter to check for resistance after inflating the
balloon. - -Lubricates the first 2.5 to 5 cm (2 in) of the catheter.
The nurse should lubricate the first 2.5 to 5 cm (1 to 2 in) of the catheter
when inserting a catheter into a female client. The nurse should lubricate
the first 15 to 17.5 cm (6 to 7 in) when inserting a catheter into a male
client. cleaning the client's meatus.
- A charge nurse is observing a nurse insert an indwelling urinary
catheter into a female client. For which of the following actions by the
nurse should the charge nurse intervene?
a. The nurse separates the client's labia with her dominant hand.
b. The nurse coats the indwelling urinary catheter with lubricant.
c. The nurse provides perineal care prior to inserting the urinary catheter.
d. The nurse applies the sterile drape prior to inserting the urinary
catheter. - -The nurse separates the client's labia with her dominant hand.
, The nurse should use her non-dominant hand to separate the labia, or to
hold the penis in male clients. The dominant hand is the hand that should
handle the catheter during insertion and when filling the balloon. If the
nurse separated the labia with her dominant hand, it would be more
difficult to insert the catheter in a sterile environment and could result in
introduction of bacteria into the urinary tract.
- A client who has an elevated BUN is most likely to have a
manifestation of
a. A client who reports painful urination of a
b. A client who reports urinary frequency
c. A client who has glucose in his urine - -A client who reports urinary
frequency
Voiding a small amount of urine (less than 100 mL) frequently (2 to 3
times per hr), and dribbling of urine are manifestations of urinary
retention.
- A nurse assessing a client notes that the client has a constant leakage
of small amounts of urine and a bladder that is distended and palpable.
The nurse should associate these findings with which of the following
types of urinary incontinence?
a. Stress incontinence
b. Urge incontinence
c. Overflow incontinence
d. Reflex incontinence - -Overflow incontinence
These findings are associated with overflow incontinence, which occurs
when the pressure of urine in an overfull bladder overcomes sphincter
control.
- A nurse in a clinic is assessing a client who has a new diagnosis of
interstitial cystitis. The nurse should expect which of the following?
a. Negative urine culture
b. Denies urgency
c. Denies pain with urination
d. Fever - -Negative urine culture
A laboratory finding of a negative urine culture is consistent with a
diagnosis of interstitial cystitis since it is a non-infectious process.
- A nurse in a long-term care facility is caring for an older adult client
who has dementia and begins to have frequent episodes of urinary
incontinence. After the provider determines no medical cause for the
client's incontinence, which of the following interventions should the nurse
initiate to manage this behavior?
