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A patient has a flaccid bladder secondary to a spinal cord injury. The nurse recognizes this patients high risk for urinary retention and should implement what intervention in the patients plan of care?
- A. Relaxation techniques
- B. Sodium restriction
- C. Lower abdominal massage
- D. Double voiding
Correct Answer: D
Rationale: To enhance emptying of a flaccid bladder, the patient may be taught to double void. After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2 minutes, and then attempt to void again in an effort to further empty the bladder. Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction and massage are similarly ineffective.
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A patient with a sacral pressure ulcer has had a urinary catheter inserted. As a result of this new intervention, the nurse should prioritize what nursing diagnosis in the patients plan of care?
- A. Impaired physical mobility related to presence of an indwelling urinary catheter
- B. Risk for infection related to presence of an indwelling urinary catheter
- C. Toileting self-care deficit related to urinary catheterization
- D. Disturbed body image related to urinary catheterization
Correct Answer: B
Rationale: Catheters create a high risk for UTIs. Because of this acute physiologic threat, the patients risk for infection is usually prioritized over functional and psychosocial diagnoses.
The clinic nurse is preparing a plan of care for a patient with a history of stress incontinence. What role will the nurse have in implementing a behavioral therapy approach?
- A. Provide medication teaching related to pseudoephedrine sulfate.
- B. Teach the patient to perform pelvic floor muscle exercises.
- C. Prepare the patient for an anterior vaginal repair procedure.
- D. Provide information on periurethral bulking.
Correct Answer: B
Rationale: Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the cornerstone of behavioral intervention for addressing symptoms of stress, urge, and mixed incontinence. None of the other listed interventions has a behavioral approach.
An adult patient has been hospitalized with pyelonephritis. The nurses review of the patients intake and output records reveals that the patient has been consuming between3 \mathrm{~L}$ and3.5 \mathrm{~L}$ of oral fluid each day since admission. How should the nurse best respond to this finding?
- A. Supplement the patients fluid intake with a high-calorie diet.
- B. Emphasize the need to limit intake to2 \mathrm{~L}$ of fluid daily.
- C. Obtain an order for a high-sodium diet to prevent dilutional hyponatremia.
- D. Encourage the patient to continue this pattern of fluid intake.
Correct Answer: D
Rationale: Unless contraindicated, 3 to4 \mathrm{~L}$ of fluids per day is encouraged to dilute the urine, decrease burning on urination, and prevent dehydration. No need to supplement this fluid intake with additional calories or sodium.
The nurse has implemented a bladder retraining program for an older adult patient. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void. The nurse notes that the patient typically has approximately50 \mathrm{~mL}$ of urine remaining in her bladder after voiding. What would be the nurses best response to this finding?
- A. Perform a straight catheterization on this patient.
- B. Avoid further interventions at this time, as this is an acceptable finding.
- C. Place an indwelling urinary catheter.
- D. Press on the patients bladder in an attempt to encourage complete emptying.
Correct Answer: B
Rationale: In adults older than 60 years of age, 50 to100 \mathrm{~mL}$ of residual urine may remain after each voiding because of the decreased contractility of the detrusor muscle. Consequently, further interventions are not likely warranted.
The nurse is caring for a patient who has undergone creation of a urinary diversion. Forty-eight hours postoperatively, the nurses assessment reveals that the stoma is a dark purplish color. What is the nurses most appropriate response?
- A. Document the presence of a healthy stoma.
- B. Assess the patient for further signs and symptoms of infection.
- C. Inform the primary care provider that the vascular supply may be compromised.
- D. Liaise with the wound-ostomy-continence (WOC) nurse because the ostomy appliance around the stoma may be too loose.
Correct Answer: C
Rationale: A healthy stoma is pink or red. A change from this normal color to a dark purplish color suggests that the vascular supply may be compromised. A loose ostomy appliance and infections do not cause a dark purplish stoma.