Nokea
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.
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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 is caring for a patient with an enlarged prostate who has had an indwelling catheter for several weeks. A prescription for continuous bladder irrigation (CBI) is written after the patient developed hematuria post cystoscopy. The nurse teaches the patient the purpose of CBI is to prevent what situation?
- A. Catheter infection due to long-term use
- B. Need to flush the catheter of organisms post procedure
- C. Blood clots that could block the catheter
- D. Need for increased fluid intake
Correct Answer: C
Rationale: Post procedure continuous bladder irrigation, in the presence of hematuria, prevents stasis of blood and clot formation potentially obstructing urine output. In the absence of hematuria, clots or debris, natural irrigation of the catheter through increased fluid intake by the patient is preferred. It is preferable to avoid catheter irrigation unless necessary to relieve or prevent obstruction.
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 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.