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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.
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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.
A nurse who provides care in a long-term care facility is aware of the high incidence and prevalence of urinary tract infections among older adults. What action has the greatest potential to prevent UTIs in this population?
- A. Administer prophylactic antibiotics as ordered.
- B. Limit the use of indwelling urinary catheters.
- C. Encourage frequent mobility and repositioning.
- D. Toilet residents who are immobile on a scheduled basis.
Correct Answer: B
Rationale: When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their use significantly reduces an older adults risk of developing a UTI. Regular toileting promotes continence, but has only an indirect effect on the risk of UTIs. Prophylactic antibiotics are not normally administered. Mobility does not have a direct effect on UTI risk.
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.
A patient with kidney stones is scheduled for extracorporeal shock wave lithotripsy (ESWL). What should the nurse include in the patients post-procedure care?
- A. Strain the patients urine following the procedure.
- B. Administer a bolus of500 \mathrm{~mL}$ normal saline following the procedure.
- C. Monitor the patient for fluid overload following the procedure.
- D. Insert a urinary catheter for 24 to 48 hours after the procedure.
Correct Answer: A
Rationale: Following ESWL, the nurse should strain the patients urine for gravel or sand. There is no need to administer an IV bolus after the procedure and there is not a heightened risk of fluid overload. Catheter insertion is not normally indicated following ESWL.
A patient who has recently undergone ESWL for the treatment of renal calculi has phoned the urology unit where he was treated, telling the nurse that he has a temperature of101.1 \mathrm{~F}(38.4 \mathrm{C})$. How should the nurse best respond to the patient?
- A. Remind the patient that renal calculi have a noninfectious etiology and that a fever is unrelated to their recurrence.
- B. Remind the patient that occasional febrile episodes are expected following ESWL.
- C. Tell the patient to report to the ED for further assessment.
- D. Tell the patient to monitor his temperature for the next 24 hours and then contact his urologists office.
Correct Answer: C
Rationale: Following ESWL, the development of a fever is abnormal and is suggestive of a UTI; prompt medical assessment and treatment are warranted. It would be inappropriate to delay further treatment.