Nokea
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.
You may also like to solve these questions
A patient has been admitted to the medical unit with a diagnosis of ureteral colic secondary to urolithiasis. When planning the patients admission assessment, the nurse should be aware of the signs and symptoms that are characteristic of this diagnosis? Select all that apply.
- A. Diarrhea
- B. High fever
- C. Hematuria
- D. Urinary frequency
- E. Acute pain
Correct Answer: C,D,E
Rationale: Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a desire to void, but little urine is passed, and it usually contains blood because of the abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is not associated with this presentation and a fever is usually absent due to the noninfectious nature of the health problem.
A nurse is working with a female patient who has developed stress urinary incontinence. Pelvic floor muscle exercises have been prescribed by the primary care provider. How can the nurse best promote successful treatment?
- A. Clearly explain the potential benefits of pelvic floor muscle exercises.
- B. Ensure the patient knows that surgery will be required if the exercises are unsuccessful.
- C. Arrange for biofeedback when the patient is learning to perform the exercises.
- D. Contact the patient weekly to ensure that she is performing the exercises consistently.
Correct Answer: C
Rationale: Research shows that written or verbal instruction alone is usually inadequate to teach an individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel control. Biofeedback-assisted pelvic muscle exercise (PME) uses either electromyography or manometry to help the individual identify the pelvic muscles as he or she attempts to learn which muscle group is involved when performing PME. This objective assessment is likely superior to weekly contact with the patient. Surgery is not necessarily indicated if behavioral techniques are unsuccessful.
A female patients most recent urinalysis results are suggestive of bacteriuria. When assessing this patient, the nurses data analysis should be informed by what principle?
- A. Most UTIs in female patients are caused by viruses and do not cause obvious symptoms.
- B. A diagnosis of bacteriuria requires three consecutive positive results.
- C. Urine contains varying levels of healthy bacterial flora.
- D. Urine samples are frequently contaminated by bacteria normally present in the urethral area.
Correct Answer: D
Rationale: Because urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding10^5$ colonies/ \mathrm{mL}$ of clean-catch, midstream urine is the measure that distinguishes true bacteriuria from contamination. A diagnosis does not require three consecutive positive results and urine does not contain a normal flora in the absence of a UTI. Most UTIs have a bacterial etiology.
The nurse is collaborating with the wound-ostomy-continence (WOC) nurse to teach a patient how to manage her new ileal conduit in the home setting. To prevent leakage or skin breakdown, the nurse should encourage which of the following practices?
- A. Empty the collection bag when it is between one-half and two-thirds full.
- B. Limit fluid intake to prevent production of large volumes of dilute urine.
- C. Reinforce the appliance with tape if small leaks are detected.
- D. Avoid using moisturizing soaps and body washes when cleaning the peristomal area.
Correct Answer: D
Rationale: The patient is instructed to avoid moisturizing soaps and body washes when cleaning the area because they interfere with the adhesion of the pouch. To maintain skin integrity, a skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the collection bag should not be allowed to become more than one-third full.
A patient with cancer of the bladder has just returned to the unit from the PACU after surgery to create an ileal conduit. The nurse is monitoring the patients urine output hourly and notifies the physician when the hourly output is less than what?
- A. $30 \mathrm{~mL}$
- B. $50 \mathrm{~mL}$
- C. $100 \mathrm{~mL}$
- D. $125 \mathrm{~mL}$
Correct Answer: A
Rationale: A urine output below30 \mathrm{~mL} / \mathrm{hr}$ may indicate dehydration or an obstruction in the ileal conduit, with possible backflow or leakage from the ureteroileal anastomosis.