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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.
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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.
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 caring for a patient who just began hemodialysis assesses the patient's AV fistula. Nursing documentation includes: '5/10/25 0930 AV fistula in the right forearm negative for thrill and bruit. Patient denies pain and tenderness.' Which finding is essential for the nurse report to the health care provider?
- A. Thrill and bruit are absent.
- B. Area is without redness or swelling.
- C. Patient denies pain and tenderness.
- D. Trace edema of the fingers is present.
Correct Answer: A
Rationale: The nurse palpates and auscultates over the access site, feeling for a thrill or vibration and listening for the bruit or swishing sound. Presence of the thrill and bruit are normal findings, indicating patency of the access. Decreased or absent thrill and/or bruit indicates that there is an issue with the patency of the access, which could be a result of narrowing or clotting of the access, resulting in poor blood flow. No report of pain, redness, or swelling is a normal finding. A trace of edema is not a priority.
A nurse receives a prescription to catheterize a patient following surgery. What nursing action reflects correct technique?
- A. Planning to use different equipment for catheterization of male versus female patients
- B. Selecting the smallest appropriate size indwelling urinary catheter
- C. Sterilizing the equipment prior to insertion
- D. Avoiding filling the balloon with sterile water to prevent pressure on tissues
Correct Answer: B
Rationale: The smallest appropriate indwelling urinary catheter should be selected to aid in prevention of CAUTIs in the adult hospitalized patient. The equipment used for catheterization is usually prepackaged in a sterile, disposable tray and is the same for both male and female patients. Most kits already contain a standard-sized catheter. Catheters are graded on the French (F) scale according to lumen size, with 12 to 16 Fr gauge commonly used. A 14F, 5-mL or 10-mL balloon is usually appropriate, unless ordered otherwise.
A nurse on a pediatric surgical unit notes a 10-year-old child has developed nocturnal enuresis. What health concern will the nurse plan for?
- A. Constipation
- B. Bedwetting after the age of toilet training
- C. Patient who is manipulative
- D. Infection
Correct Answer: B
Rationale: Urinary incontinence of urine past the age of toilet training is termed enuresis. Hospitalization may cause regression of toileting habits.