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The licensed practical nurse is employed as a charge nurse at a long-term care facility. A resident is ordered a catheterization schedule of every 6 hours due to chronic urinary retention. The LPN reports daily catheterization amounts from the previous day ranging from 450 mL to 800 mL. Which nursing action is most correct?
- A. Continue the same order
- B. Obtain an order to decrease the frequency of the catheterizations
- C. Obtain an order to increase the frequency of the catheterizations
- D. Leave the catheterer in if obtaining a urine amount over 500 mL
Correct Answer: C
Rationale: The charge nurse realizes that if the volume of urine obtained via catheterization is more than 400 mL, the client should be catheterized more often. The LPN would call for a change in orders citing the urine volume as the rationale. Leaving the catheter in place is only completed if necessary.
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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.
A nurse is reviewing the history and physical examination of a client with a suspected malignant tumor of the bladder. Which finding would the nurse identify as the most common initial symptom?
- A. Urinary retention
- B. Fever
- C. Frequency
- D. Painless hematuria
Correct Answer: D
Rationale: The most common first symptom of a malignant tumor of the bladder is painless hematuria. Additional early symptoms include UTI with symptoms such as fever, dysuria, urgency, and frequency. Later symptoms are related to metastases and include pelvic pain, urinary retention (if the tumor blocks the bladder outlet), and urinary frequency from the tumor occupying bladder space.
The nurse is caring for several clients on a urinary medical unit. Which client is at an increased risk for bladder stones?
- A. The client with frequent urinary tract infections
- B. The client who is paraplegic
- C. The client with difficulty ambulating
- D. The client with abdominal surgery
Correct Answer: B
Rationale: The client who is immobile or who is paraplegic may also tend to form bladder stones. Clients with incomplete urinary elimination, urinary stasis, or concentrated urine are at higher risk for stone formation. There is not as strong correlation between infections, difficulty ambulating, and surgery.
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.
The nurse is caring for a client diagnosed with bladder cancer and requiring a cystectomy. The nurse overhears the physician instructing the client on the presence of a stoma with temporary pouch. In gathering information for the client, which urinary diversion would the nurse select?
- A. Ileal conduit
- B. Kock Pouch
- C. Ureterosigmoidostomy
- D. Indiana Pouch
Correct Answer: A
Rationale: When the physician is discussing a stoma, the nurse recognizes that the client will have an ileal conduit which is a cutaneous urinary diversion. Both the Kock Pouch and Indiana Pouch are continent urinary diversions. The ureterosigmoidostomy connects with the rectum for urinary drainage.