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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.
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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 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.
The nurse observes a client's uric acid level of 9.3 mg/dL. When teaching the client about ways to decrease the uric acid level, which diet would the nurse suggest?
- A. A low-sodium diet
- B. A low-purine diet
- C. A diet high in fruits and vegetables
- D. A diet high in calcium
Correct Answer: B
Rationale: The nurse would suggest a low-purine diet. Foods to avoid are anchovies, animal organs, and sardines. The other options do not lower the uric acid levels.
The nurse is caring for a 37-year-old female client with potential interstitial cystitis. Which question, asked by the nurse, is helpful in supporting the diagnosis?
- A. Have you noted any unusual vaginal drainage?
- B. Have you experienced hematuria with cramping?
- C. When was your last menstrual period?
- D. Do you drink alcoholic beverages on a frequent basis?
Correct Answer: C
Rationale: Although the cause of interstitial cystitis is unknown, there appears to be a connection with female hormones as a link between flare-ups prior to menstruation has been noted. Unusual vaginal drainage is a symptom of a sexually transmitted disease. Hematuria is a symptom of many urinary tract disorders and not helpful in specifically suggesting interstitial cystitis. Alcoholic beverage consumption is not an indicator.
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.