. The nurse is caring for a patient who has urinary retention resulting from benign prostatic hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder. Which action will the nurse take to facilitate this procedure?
a. Obtain a Coudé catheter for inserti...
The nurse is caring for a patient who is recovering from septic shock. While in the ICU, the patient
developed renal failure. The nurse recognizes which type of renal failure the patient most likely
developed?
a. Prerenal
b. Renal
c. Postrenal
d. Mixed
a
The nurse is caring for a patient with a neurological condition that causes constant severe thirst,
drinking fluids continuously, and voiding 3 to 4 L of clear yellow urine daily. Which term will the nurse
use in the record to describe this patient's urinary output?
a. Anuria
b. Oliguria
c. Polyuria
d. Enuresis
c
The nurse is caring for a patient who is experiencing stress incontinence. The nurse identifies which
goal to be the most important for this patient?
a. The patient will carefully complete a voiding diary for the duration of 2 weeks.
b. The patient will not experience involuntary urination during coughing or sneezing.
c. The patient will be able to recognize and effectively manage perineal dermatitis.
d. The patient will demonstrate how to appropriately use urinary incontinence products.
b
The nurse is caring for a postoperative patient whose urinary catheter was removed 8 hours
previously. The patient has not been able to void since the catheter was removed and now reports
suprapubic pain. What is the priority action of the nurse?
a. Encourage oral fluid intake and administer a diuretic.
b. Obtain a urine sample to test for culture and sensitivity.
c. Calculate the patient's daily intake and output.
d. Obtain an order to straight-catheterize the patient
,d
The nurse is caring for a patient who recently underwent ileal conduit surgery. Which nursing
diagnosis is the highest priority for this patient?
a. Impaired sexual function related to changed body structure
b. Social isolation related to potential for accidental leakage of urine
c. Lack of knowledge related to care and maintenance of ostomy appliance
d. Disturbed body image related to presence of stoma and appliance
c
The nurse is caring for a patient who reports an urgent need to urinate but is unable to pass more
than a few drops of urine in the toilet. Which is the priority assessment to be performed by the nurse?
a. Bladder scan to determine the amount of urine in the bladder
b. Auscultation to assess circulation through the right and left renal arteries
c. Bimanual palpation to assess for possible enlargement of the kidneys
d. Calculate the patient's intake and output to check for fluid volume deficit
a
The nurse is caring for a seriously ill patient whose laboratory results show a serum creatinine level of
3.5 mg/dL and a serum BUN of 35 mg/dL. Which conclusion can the nurse draw from these test
results?
a. The patient is severely dehydrated.
b. The patient's kidneys have been damaged.
c. The patient has a urinary tract infection.
d. The patient has developed a renal calculus
b
The nurse is caring for a patient who has developed kidney failure. Which test finding leads the nurse
to contact the nephrologist and arrange for emergency hemodialysis?
a. Potassium level 6.8 mmol/L
b. Serum creatinine level of 2.8 mg/dL
c. Large amounts of protein in the urine
d. 1500 mL of retained urine in the bladder
a
he nurse is caring for a patient who will undergo ultrasound testing of the bladder and kidneys the
next morning. Which instruction will the nurse provide to the patient about the test?
a. "A small IV will be inserted into your arm to inject the contrast dye."
b. "You will need to drink lots of water but not use the toilet."
c. "You should not have anything to eat or drink after midnight."
d. "You will receive a cleansing enema before you have the test."
b
,. The nurse is caring for a patient who has urinary retention resulting from benign prostatic
hyperplasia (BPH). The patient requires catheterization in order to drain the urine from his bladder.
Which action will the nurse take to facilitate this procedure?
a. Obtain a Coudé catheter for insertion.
b. Attach a leg bag to the catheter prior to insertion.
c. Trim the pubic hair before cleaning the perineal area.
d. Wait until the bladder is full to perform catheterization.
a
The nurse is caring for an incontinent male patient who has a deep decubitus ulcer on his sacrum.
Which intervention will best manage the patient's urinary incontinence and facilitate healing of the
ulcer? a. Use of disposable absorbable incontinence briefs
b. Daily application of perineal barrier cream containing zinc oxide
c. Careful perineal care and application of a condom catheter
d. Insertion of a single-lumen straight urinary catheter
c
The nurse is caring for a patient who has urinary frequency. Which nursing diagnosis is the highest
priority for this patient?
a. Impaired urination r/t occasional incontinence
b. Anxiety r/t living alone at home with nocturia
c. Risk for infection r/t urine contact with perineal area skin
d. Risk for fall-related injury r/t hurried trips to the bathroom during the day and night
d
The nurse is caring for a patient who has just had an intravenous pyelography (IVP) completed. Which
assessment is the nurse's highest priority after the patient returns from the test?
a. Calculate the patient's intake and output.
b. Monitor for discoloration of the patient's urine.
c. Assess for possible iodine or shellfish allergies.
d. Inquire if the patient has burning or pain with urination
a
The nurse is caring for a patient with benign prostatic hypertrophy who states that he feels a constant
urge to urinate but cannot pass more than 30 to 60 mL of urine at a time. The nurse performs a
bladder scan and finds that there are 1100 mL of urine in the patient's bladder. What is the priority
nursing diagnosis for this patient?
a. Anxiety r/t continual urge to urinate
b. Reflex incontinence of urine r/t over-distention of the bladder
c. Impaired urination r/t obstruction of urinary bladder outlet
d. Impaired self-toileting r/t inability to pass urine into the toilet
c
, The nurse is caring for a patient who had prostate surgery the previous day. The patient has had
significantly decreased urine output over the last shift despite ample oral and IV fluid intake. The
patient's urine from the indwelling catheter is cherry red with occasional small clots. What is the
appropriate action of the nurse?
a. Remove the urinary catheter and replace it with a new one.
b. Gently irrigate the catheter using warmed sterile normal saline.
c. Send a sample of the patient's urine to the laboratory for analysis. d. Call the provider and obtain an
order for kidney and bladder ultrasound.
b
The nurse is caring for a patient with the nursing diagnosis of Urge incontinence of urine related to
urinary tract infection. Which statement is appropriate for the "as evidenced by" portion of the
patient's diagnosis?
a. Sudden leakage of urine when patient is unable to get to the toilet in time
b. Continuous urine flow from the bladder regardless of attempts to use the toilet
c. Leakage of urine from the bladder when the patient coughs, sneezes, or laughs
d. Leakage of urine because the patient is unable to indicate need to use the toilet
a
The nurse is caring for a patient with an indwelling urinary catheter caused by severe prostate
enlargement. Which is the priority nursing diagnosis for this patient?
a. Risk for infection r/t indwelling urinary catheter
b. Disturbed body image r/t presence of catheter
c. Risk for contamination r/t potential leakage of urine on clothing
d. Impaired urination r/t blockage of bladder outlet
a
The preceptor is watching a nursing student care for a male patient who requires a condom catheter.
Which action by the nursing student indicates that the procedure is performed correctly?
a. Sterile gloves are donned before touching the catheter.
b. Adhesive tape is applied securely around the base of the penis.
c. Water-soluble lubricant is applied to the end of the catheter.
d. The foreskin is returned to its natural position before the catheter is applied.
d
The nurse is caring for a patient with a history of type 1 diabetes. Which assessment finding indicates
to the nurse that the patient may not be compliant with the diabetic treatment regimen?
a. The patient is always thirsty and frequently voids very large amounts of urine.
b. The patient's urine is very concentrated with a dark amber color. c. The patient complains of
throbbing flank pain and burning with urination.
d. The patient has urinary hesitancy and difficulty initiating a stream of urine.
a
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