Nokea
The nurse is admitting an older-adult patient with dehydration who is confused and incontinent of urine. Which of the following nursing actions is best to include in the plan of care?
- A. Apply absorbent incontinent pads.
- B. Restrict fluids after the evening meal.
- C. Insert an indwelling catheter until the symptoms have resolved.
- D. Assist the patient to the bathroom every 2 hours during the day.
Correct Answer: D
Rationale: In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.
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The nurse is teaching a patient with interstitial cystitis about management of the condition. Which of the following patient statements indicate that further instruction is required?
- A. I will have to stop having coffee and orange juice for breakfast.
- B. I should start taking a high potency multiple vitamin every morning.
- C. I will buy some calcium glycerophosphate (Prelief) at the pharmacy.
- D. I should call the doctor about increased bladder pain or odorous urine.
Correct Answer: B
Rationale: High-potency multiple vitamins may irritate the bladder and increase symptoms. The other patient statements indicate good understanding of the teaching.
The nurse is caring for a patient who has bladder cancer and had a cystectomy with creation of an Indiana pouch. Which of the following topics should the nurse include in patient teaching?
- A. Application of ostomy appliances
- B. Catheterization technique and schedule
- C. Analgesic use before emptying the pouch
- D. Use of barrier products for skin protection
Correct Answer: B
Rationale: The Indiana pouch enables the patient to self-catheterize every 4-6 hours. There is no need for an ostomy device or barrier products. Catheterization of the pouch is not painful.
The nurse is caring for a patient whose renal calculus is analyzed as being very high in uric acid. To prevent recurrence of stones, which of the following foods should the nurse teach the patient to avoid eating?
- A. Milk and dairy products
- B. Legumes and dried fruits
- C. Organ meats and sardines
- D. Spinach, chocolate, and tea
Correct Answer: C
Rationale: Organ meats and fish such as sardines increase purine levels and uric acid. Spinach, chocolate, and tomatoes should be avoided in patients who have oxalate stones. Milk, dairy products, legumes, and dried fruits may increase the incidence of calcium-containing stones.
Which of the following findings for a patient who has had a cystectomy with an ileal conduit the previous day is most important for the nurse to communicate to the health care provider?
- A. Cloudy appearing urine
- B. Hypotonic bowel sounds
- C. Heart rate 102 beats/minute
- D. Stoma appears pale and dry
Correct Answer: D
Rationale: A pale and dry stoma indicates poor vascularity or ischemia, which is a critical complication requiring immediate reporting to the health care provider. Cloudy urine, hypotonic bowel sounds, and a slightly elevated heart rate are common postoperative findings but are less urgent unless accompanied by other critical symptoms.
The nurse is caring for a patient with benign prostatic hyperplasia (BPH) and a markedly distended bladder who is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first?
- A. Insert a urinary retention catheter.
- B. Schedule an intravenous pyelogram.
- C. Administer lorazepam 0.5 mg PO.
- D. Draw blood for blood urea nitrogen (BUN) and creatinine testing.
Correct Answer: A
Rationale: The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently.