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The best nursing action to remove urine from the bladder is to use a curve-tipped coud?© catheter
- A. Use a large catheter such as a 22 French
- B. Use a straight-tipped catheter
- C. Crec?º maneuver
Correct Answer: C
Rationale: The best nursing action to remove urine from the bladder is to use a curve-tipped coud?© catheter. The coud?© catheter has a curved tip to slide over the obstruction. Using a large catheter such as a 22 French would meet resistance and traumatize the urethral lining. A straight-tipped catheter also would meet the obstruction and not advance. Crec?º maneuver may eliminate a small amount of urine but does nothing to allow urine flow around the narrowing.
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The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?
- A. Coffee in the morning
- B. Fruit juice midmorning
- C. Milk at lunch
- D. Ginger ale at dinner time
Correct Answer: A
Rationale: The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.
The nurse is obtaining a health history from a client describing urinary complications. Which assessment finding is most suggestive of an early stage of malignant tumor of the bladder?
- A. Incontinence
- B. Dysuria
- C. Hematuria
- D. Frequency
Correct Answer: C
Rationale: The most common first symptom of a malignant tumor is painless hematuria. Most malignant tumors are vascular, thus, abnormal bleeding can be a first sign of abnormality. The client then has symptoms of incontinence (a later sign), dysuria, and frequency.
A nurse coming from morning report is instructed to use a bladder scanner on a client following a client's attempt at urination. The client is able to void 300 ml. The client denies any pain on urination. The nurse scans 250 ml of remaining urine in the bladder. Which entry is most correct when documenting the intervention?
- A. Client voided 300 ml without dysuria
- B. Client voided 500 mL of urine for the daylight shift
- C. Client voided 300 mL with 250 mL residual volume
- D. Bladder scanning resulted in 250 mL
Correct Answer: C
Rationale: When documenting the results of using a bladder scanner, it is best to note the amount voided and then the residual urine remaining in the bladder. This documentation enables the analysis of the client's ability to empty the bladder.
An older adult client is participating in a bladder retraining program as part of the treatment for urinary incontinence. The nurse advises the client to wear barrier garments such as liners and protective pants. Which suggestion would be most appropriate to help the client maintain skin integrity?
- A. Avoiding the application of moisture sealant
- B. Exposing the affected area to air
- C. Using scented sprays or perfumes
- D. Avoiding using an electric room deodoriorer
Correct Answer: B
Rationale: Exposing the affected area to air helps maintain skin integrity by reducing moisture, which can lead to skin breakdown in incontinent clients. Avoiding moisture sealant may increase irritation, and scented sprays or perfumes can cause further irritation. Electric room deodorizers do not directly impact skin integrity.
The nurse is caring for a client who is following a treatment plan to decrease urinary tract infections. What indicates the need to change the treatment plan?
- A. The client has history of repeated antibiotic therapy
- B. The client has improved personal hygiene methods
- C. The client exhibits continued symptoms
- D. The client has diluted urine
Correct Answer: C
Rationale: If the client exhibits continued symptoms, the treatment plan is ineffective and the plan needs to be revised. Having a history of antibiotic therapy indicates the need to establish a treatment plan. Having improved hygiene indicates that the client is following the treatment plan. Having diluted urine indicates that the client has increased fluids which are a plan of typical treatment plans.