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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.
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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 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.
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 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.
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.