Nokea
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.
You may also like to solve these questions
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.
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 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 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 patient who has pneumonia has had a fever for 3 days. What characteristics would the nurse anticipate related to the patient's urine output?
- A. Decreased amount and highly concentrated
- B. Decreased amount and very pale like water
- C. Increased amount and very concentrated
- D. Increased amount and dilute appearing
Correct Answer: A
Rationale: Fever and diaphoresis cause the kidneys to conserve body fluids. Thus, the urine is concentrated and decreased in amount.