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A nurse in the emergency room is teaching a patient how to collect a midstream urine specimen. What instructions will the nurse give the patient?
- A. Wash your hands with soap and water.
- B. Open the container and place the lid face down on the counter.
- C. Separate your labia and wipe with the antiseptic towelettes in the kit.
- D. Without letting go of the labia, void a small amount into the toilet or collection hat.
- E. Lean the collection container against the urinary opening and void into the container.
- F. Void an ounce, then remove the container and finish voiding in the toilet.
Correct Answer: A,C,D
Rationale: The nurse gives these instructions to collect the midstream/clean-catch urine specimen: Wash your hands with soap and water. Open the collection cup, and place the lid face up; do not touch the inside. Separate the labia and cleanse the urinary opening with soap and water or towelettes included in the kit. Void about 1 oz. (30 mL) into the toilet, then move the collection cup close to the urinary opening and void about 1 oz (no less than 2 teaspoons) into the container. Pass the remainder of the urine into the toilet. Without touching the inside of the lid, close the cup and return it to the nurse.
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A nurse in the gynecology clinic is preparing an educational brochure to teach patients how to prevent UTIs. Which teaching points would the nurse include?
- A. Wear underwear with a cotton crotch.
- B. Take baths rather than showers.
- C. Drink of six to eight 8-oz glasses of liquid per day.
- D. Urinate before and after intercourse.
- E. After defecation, dry the perineal area from the front to the back.
- F. Observe the urine for color, amount, odor, and frequency.
Correct Answer: A,C,D,E
Rationale: It is recommended that a healthy adult drink six to eight 8-oz glasses of fluid daily, dry the perineal area after urination or defecation from the front to the back, and observe the urine for color, amount, odor, and frequency. It is also recommended to wear underwear with a cotton crotch, take showers rather than baths, and drink two glasses of water before and after sexual intercourse and void immediately after intercourse. Observing urine characteristics will not prevent a UTI; however, this observation may help a patient notice an infection.
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 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.
A nurse is caring for an alert, ambulatory, older adult with urinary frequency who has difficulty making it to the bathroom in time. Which nursing intervention is most appropriate to include in the care plan for this patient?
- A. Explaining that incontinence is an expected occurrence with aging
- B. Asking the patient's family/caregivers to purchase incontinence pads for the patient
- C. Teaching the patient how to perform PFMT exercises at regular intervals
- D. Inserting an indwelling catheter to prevent skin breakdown
Correct Answer: C
Rationale: Pelvic floor exercises (Kegel exercises) may help a patient regain control of the micturition. Incontinence is not a normal consequence of aging. Using absorbent products may remove motivation from the patient and caregiver to seek evaluation and treatment of the incontinence; they should be used only after careful evaluation by a health care provider. Due to risk for infection, an indwelling catheter is the last choice of treatment.
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.