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A nurse is changing the stoma appliance on a patient's ileal conduit. Which finding requires the nurse to follow up with the provider?
- A. Stoma is moist.
- B. Skin around the stoma is irritated.
- C. Urine is leaking from the stoma.
- D. Stoma is a purple-black color.
Correct Answer: D
Rationale: The stoma should appear pink to red, shiny, and moist; a dark brown or purple-blue stoma may reflect compromised circulation. The nurse contacts the health care provider immediately. A urostomy is incontinent; urine leakage is expected.
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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.
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 nurse caring for older adults in an extended-care facility performs regular assessments of the patients' urinary functioning. Which patients would the nurse identify as at risk for urinary retention?
- A. Patient who is diagnosed with an enlarged prostate
- B. Patient who is on bedrest
- C. Patient who is diagnosed with vaginal prolapse
- D. Older adult patient with dementia
- E. Patient who is taking antihistamines to treat allergies
- F. Patient who has difficulty walking to the bathroom
Correct Answer: A,C,E
Rationale: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications such as antihistamines, an enlarged prostate, or vaginal prolapse. Being on bedrest, having dementia, and having difficulty walking to the bathroom may place patients at risk for urinary incontinence.
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 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.