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A nurse coming from morning report is instructed to use a bladder scanner on a client following a client's attempt at urination. The client is able to void 300 ml. The client denies any pain on urination. The nurse scans 250 ml of remaining urine in the bladder. Which entry is most correct when documenting the intervention?
- A. Client voided 300 ml without dysuria
- B. Client voided 500 mL of urine for the daylight shift
- C. Client voided 300 mL with 250 mL residual volume
- D. Bladder scanning resulted in 250 mL
Correct Answer: C
Rationale: When documenting the results of using a bladder scanner, it is best to note the amount voided and then the residual urine remaining in the bladder. This documentation enables the analysis of the client's ability to empty the bladder.
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The nurse observes a client's uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest?
- A. A low-sodium diet
- B. A low-purine diet
- C. A diet high in fruits and vegetables
- D. A diet high in calcium
Correct Answer: B
Rationale: The nurse would suggest a low-purine diet. Foods to avoid are anchovies, animal organs, and sardines. The other options do not lower the uric acid levels.
The nurse is obtaining a health history from a client describing urinary complications. Which assessment finding is most suggestive of an early stage of malignant tumor of the bladder?
- A. Incontinence
- B. Dysuria
- C. Hematuria
- D. Frequency
Correct Answer: C
Rationale: The most common first symptom of a malignant tumor is painless hematuria. Most malignant tumors are vascular, thus, abnormal bleeding can be a first sign of abnormality. The client then has symptoms of incontinence (a later sign), dysuria, and frequency.
An older adult client is participating in a bladder retraining program as part of the treatment for urinary incontinence. The nurse advises the client to wear barrier garments such as liners and protective pants. Which suggestion would be most appropriate to help the client maintain skin integrity?
- A. Avoiding the application of moisture sealant
- B. Exposing the affected area to air
- C. Using scented sprays or perfumes
- D. Avoiding using an electric room deodoriorer
Correct Answer: B
Rationale: Exposing the affected area to air helps maintain skin integrity by reducing moisture, which can lead to skin breakdown in incontinent clients. Avoiding moisture sealant may increase irritation, and scented sprays or perfumes can cause further irritation. Electric room deodorizers do not directly impact skin integrity.
The nurse is caring for four clients on a urinary medical unit. For which client does the nurse need no further medical interventions?
- A. The client has pain of 7 out of 10 in the mid-abodmen
- B. The client has a residual urine of 90 mL on a bedside ultrasound bladder scan
- C. The client has a WBC count of 15,00 on recent lab reports
- D. The client is unable to void in the morning hours
Correct Answer: B
Rationale: A residual urine in the bladder of 90 mL is not considered urinary retention and would need no further follow-up at this time. Client symptoms of pain need a medical order for medication. An elevated WBC count would need the attention of the physician. The client should be able to void in the morning hours, especially after the night. Further interventions may be necessary.
A client asks the nurse why cystitis is more common in women than in men. Which of the following body parts will the nurse include in the answer?
- A. The urethra
- B. The bladder
- C. The rectum
- D. The ureters
Correct Answer: A
Rationale: Because the urethra is short in women, ascending infections or microorganisms carried from the vagina or rectum are common. Males have a longer urethra, causing the organisms to travel farther to the bladder. Although structures of the urinary system, the other options are where the client has bacteria and microorganisms located. The ureters connect the bladder to kidney thus do not obtain bacteria, just transmit when available.