NUR 231 Exam 2 Questions And Answers 100% Solved
A patient is experiencing oliguria. Which action should the nurse perform first?
a. Increase the patient's intravenous fluid rate.
b. Encourage the patient to drink caffeinated beverages.
c. Assess for bladder distention.
d. Request an order for...
NUR 231 Exam 2 Questions And Answers 100% Solved
A patient is experiencing oliguria. Which action should the nurse perform first?
a. Increase the patient's intravenous fluid rate.
b. Encourage the patient to drink caffeinated beverages.
c. Assess for bladder distention.
d. Request an order for diuretics.
C - Oliguria is urine output that is decreased despite normal fluid intake. As a nurse we would assess
for bladder distention first because by gently palpating a patients bladder may cause a patient the
urge to urinate which may help us determine the urine output.
A patient requests the nurse's assistance to the bedside commode and becomes frustrated when
unable to void in front of the nurse. The nurse understands the patient's inability to void because:
a. Anxiety can make 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.
A - A nurse should understand the patients inability to void because anxiety can cause urinary
retention. When a patient normally voids it involves contraction of the bladder and coordinated
relaxation of the urethral sphincter and pelvic floor; therefore, if a patient has anxiety toward
urinating in front of the nurse or others he/she may be tense and unable to relax their muscles to
urinate. Many patients may need privacy to help prevent interruptions to allow them to relax.
An 86 year old patient tells the nurse that she is experiencing uncontrollable leakage of urine. Which
nursing diagnosis should the nurse include in the patient's plan of care?
a. Urinary retention
b. Hesitancy
c. Urgency
d. Urinary Incontinence
Urinary incontinence, which is the involuntary leakage of urine that is sufficient to be a problem.
Incontinence is more common in older adults because the intra-abdominal pressure exceeds urethral
resistance, then the muscles around the urethra become weak. Thus, allowing small amounts of urine
to leak spontaneously.
The patient expresses difficulty voiding and the constant urge to urinate. The nurse should follow up
by:
a. Using a bladder scanner to determine if there is post-void residual.
b. Telling the patient to run water when voiding.
c. Instructing the patient to perform Kegel exercises.
d. Checking the patient's vital signs.
A - The bladder scanner helps assess for post-void residual (PVR). Residual urine or post-void residual
occurs if a patient has urinary retention or cannot empty the bladder completely. This measurement
would help the nurse see if the patient has urine left in the bladder after voiding and/or if there is
another issue with voiding. A normal void the bladder should empty completely
A patient asks about treatment for urge incontinence. The nurse's best response is to advise the
patient to:
(Choose all that apply.)
a. perform pelvic floor exercises.
b. Bladder retraining
c. avoid voiding frequently.
d. Wear absorbent products.
A, B, D - Improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle
groups. The exercises are noninvasive and carry a low risk of adverse effects. In bladder training the
, goal is to reduce the voiding frequency and perhaps the bladder capacity. The retraining will hopefully
help restore a normal pattern of voiding by teaching patients to keep the patient continent.Wearing
absorbent pads promotes the comfort of a patient. An incontinent patient gains comfort from having
clean, dry clothing
To obtain a clean-catch voided urine specimen for a female patient, the nurse should teach the
patient to:
(Choose all that apply.)
a. Cleanse the urethral meatus from back to front.
b. Initiate the first part of the urine stream directly into the collection cup.
c. Hold the labia apart while voiding into the specimen cup.
d. Transport to laboratory within 15 to 30 minutes or refrigerate immediately.
C, D - If labia closes then the specimen is contaminated and becomes unsterile for laboratory
purposes. If the patient fails to hold the labia open then the procedure may have to perform again
including the perennial care. Because bacteria grow quickly in urine not received by laboratory within
30 minutes should be refrigerated
The nurse expects the urine of a patient with uncontrolled diabetes mellitus to be:
a. Cloudy
b. Discolored
c. Sweet smelling
d. painful
C - A sweet or fruity odor occurs from acetone or acetoacetic acid (by products of incomplete fat
metabolism) seen with diabetes mellitus.
A patient is having difficulty voiding in a bedpan but states that she feels her bladder is full. To
stimulate micturition, which nursing intervention should the nurse try first?
a. Exiting the room and informing the patient that the nurse will return in 30 minutes to check on the
patient's progress.
b. Utilizing the power of suggestion by turning on the faucet and letting the water run.
c. Obtaining an order for a Foley catheter.
d. Administering diuretic medication.
B - Turning the faucet on may help the patient relax his/her urethral sphincter and pelvic floor
muscles making it easier to void. Psychologically listening to the sound of water may help a person to
urinate because of the sound it makes. Also the sound of running water may help them urinate
because the nurse or others may not hear them urinate providing more privacy.
A nurse notifies the provider immediately if a patient with an indwelling catheter:
a. complains of discomfort upon insertion of the catheter.
b. places the drainage bag higher than the waist while ambulating.
c. has not collected any urine in the drainage bag for 2 hours.
d. is incontinent of stool and contaminates the external portion of the catheter.
C - Review intake record; if catheter is in the bladder and urine is absent after an hour, the nurse is to
notify physician or if urine output remains less than 30 mL per hour, notify physician.
A nurse is providing education to a patient being treated for a urinary tract infection. Which of the
following statements by the patient indicates an understanding?
a. "Since I am taking medication, I do not need to worry about proper hygiene."
b. "I should drink 15 to 20 glasses of fluid a day to help flush the bacteria out."
c. "My medication may discolor my urine; this should resolve once the medication is stopped."
d. "I should not have sexual intercourse until the infection has resolved."
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