Nokea
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.
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A nurse is caring for a patient who has a urinary diversion (urostomy) after cystectomy (removal of the bladder) to treat bladder cancer. What interventions are indicated for this patient?
- A. Measuring the patient's fluid intake and output
- B. Keeping the skin around the stoma moist
- C. Emptying the appliance frequently
- D. Reporting any mucus in the urine to the primary care provider
- E. Encouraging the patient to look away when changing the appliance
- F. Monitoring the return of intestinal function and peristalsis
Correct Answer: A,C,F
Rationale: Urinary diversion involves the surgical creation of an alternate route for excretion of urine. When caring for a patient with a urinary diversion, the nurse should measure the patient's fluid intake and output to monitor fluid balance, change the appliance frequently, monitor the return of intestinal function and peristalsis, keep the skin around the stoma dry, watch for mucus in the urine as a normal finding, and encourage the patient to participate in care and look at the stoma.
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 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.
A postoperative patient is having difficulty voiding and reports suprapubic pressure. What action can the nurse take to promote voiding?
- A. Pouring cold water over the patient's fingers and perineum
- B. Assessing bladder residual using the bladder scanner
- C. Immediately encouraging the patient to void
- D. Recommending an indwelling catheter
Correct Answer: B
Rationale: Factors associated with urinary retention include medications, an enlarged prostate, and vaginal prolapse. Assist the patient to void when the patient first feels the urge. Assessing for residual urine will not promote voiding; rather, it will determine the volume of urine in the bladder. Cold water would cause the patient to tighten their muscles.
A nurse on a pediatric surgical unit notes a 10-year-old child has developed nocturnal enuresis. What health concern will the nurse plan for?
- A. Constipation
- B. Bedwetting after the age of toilet training
- C. Patient who is manipulative
- D. Infection
Correct Answer: B
Rationale: Urinary incontinence of urine past the age of toilet training is termed enuresis. Hospitalization may cause regression of toileting habits.