Nokea
A new graduate nurse and their preceptor must collect several urine specimens for laboratory testing. Which techniques for urine collection by the graduate nurse are performed incorrectly, requiring the preceptor to intervene?
- A. Catheterizing a patient to collect a sterile urine sample for routine urinalysis
- B. Collecting a clean-catch urine specimen in the morning and storing it at room temperature until an afternoon pick-up
- C. Collecting a sterile urine specimen from the collection bag of a patient's indwelling catheter
- D. Collecting about 3 mL of urine from a patient's indwelling catheter to send for a urine culture
- E. Planning to collect a sterile specimen from a patient with a urinary diversion by catheterizing the stoma
- F. Discarding the first urine of the day when performing a 24-hour urine specimen collection on a patient
Correct Answer: B,C,D
Rationale: A urine culture requires about 3 mL of urine, whereas routine urinalysis requires at least 10 mL of urine. The preferred method of collecting a sterile urine specimen from a urinary diversion is to catheterize the stoma. For a 24-hour urine specimen, the nurse should discard the first voiding, then collect all urine voided for the next 24 hours. A sterile urine specimen is not required for a routine urinalysis. Urine chemistry is altered after urine stands at room temperature for a long period of time. A specimen from the collection drainage bag may not be fresh urine and could result in an inaccurate analysis.
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A nurse is caring for a male patient who had a urinary sheath applied following hip surgery. What nursing interventions are appropriate to include when caring for this patient?
- A. Preventing the tubing from kinking to maintain free urinary drainage
- B. Changing the sheath weekly and provide hygiene
- C. Fastening the sheath tightly to prevent the possibility of leakage
- D. Having the patient maintain bedrest to prevent the sheath from slipping off
- E. Leaving 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis
- F. Ensuring the device does not restrict blood flow.
Correct Answer: A,E,F
Rationale: Maintaining free urinary drainage is a nursing priority. Institute measures to prevent the tubing from becoming kinked and urine from backing up in the tubing. The catheter should be allowed to drain freely through tubing that is not kinked. Nursing care of a patient with a urinary sheath includes skin care to prevent excoriation. Remove the condom daily and wash the penis with soap and water, and dry it carefully. Care must be taken to fasten the sheath securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. The tip of the tubing should extend 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area. Confining a patient to bedrest increases the risk for hazards of immobility.
A nurse caring for a patient who just began hemodialysis assesses the patient's AV fistula. Nursing documentation includes: '5/10/25 0930 AV fistula in the right forearm negative for thrill and bruit. Patient denies pain and tenderness.' Which finding is essential for the nurse report to the health care provider?
- A. Thrill and bruit are absent.
- B. Area is without redness or swelling.
- C. Patient denies pain and tenderness.
- D. Trace edema of the fingers is present.
Correct Answer: A
Rationale: The nurse palpates and auscultates over the access site, feeling for a thrill or vibration and listening for the bruit or swishing sound. Presence of the thrill and bruit are normal findings, indicating patency of the access. Decreased or absent thrill and/or bruit indicates that there is an issue with the patency of the access, which could be a result of narrowing or clotting of the access, resulting in poor blood flow. No report of pain, redness, or swelling is a normal finding. A trace of edema is not a priority.
A nursing student hears in report that their patient is receiving a nephrotoxic medication. The student plans care to include what action?
- A. Teaching the patient to expect increased voiding
- B. Assessing for kidney damage
- C. Preventing urinary incontinence
- D. Observing for nocturia
Correct Answer: B
Rationale: Nephrotoxic medications are those capable of causing kidney damage. The nurse can assess I&O, quality of the urine, and renal function blood tests to detect this problem. Urinary frequency, incontinence, and getting up at night to void (nocturia) are not effects of nephrotoxic medications.
A nurse caring for older adults in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse identify as at risk for urinary retention?
- A. Patient who is diagnosed with an enlarged prostate
- B. Patient who is on bedrest
- C. Patient who is diagnosed with vaginal prolapse
- D. Older adult patient with dementia
- E. Patient who is taking antihistamines to treat allergies
- F. Patient who has difficulty walking to the bathroom
Correct Answer: A,C,E
Rationale: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.
A nurse is caring for a patient who is taking phenazopyridine (a urinary tract analgesic) for a UTI. The patient states, 'My urine was bright orange-red today; I think I'm bleeding. Something is terribly wrong.' How will the nurse best respond?
- A. The medication causes a red-orange tinge to the urine; it is expected.
- B. I will test your urine for blood.
- C. This may be the result of an injury to your bladder.
- D. I'll hold the medication and let the provider know you are allergic to the drug.
Correct Answer: A
Rationale: Phenazopyridine, a urinary tract analgesic, can cause orange or orange-red urine; the nurse educates the patient to expect this change.