Nokea
The nurse is caring for a client who has a history of urine reflux. To assess the client for this urinary complication, which nursing action is best?
- A. Ask the client if voiding sufficient quantities has been a problem.
- B. Monitor the client's intake and output for inconsistency.
- C. Have the client void into a collection device.
- D. Palpate the client's bladder for distension.
Correct Answer: D
Rationale: Normally, urine flows in one direction because of peristaltic action and because the ureters enter the bladder at an oblique angle. The reflux of urine (urine that flows backward) can occur secondary to a distended bladder. By palpating for bladder distension, the nurse is able to determine that reflux urine traveled back to the bladder instead of traveling from the bladder down the urethra. All of the other options provide data that can be helpful, but actually feeling for the distension is best. Using a bladder scanner would also provide an amount of urine in the bladder.
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A client has a full bladder. Which sound would the nurse expect to hear on percussion?
- A. Tympany
- B. Dullness
- C. Resonance
- D. Flatness
Correct Answer: B
Rationale: Dullness on percussion indicates a full bladder; tympany indicates an empty bladder. Resonance is heard over areas that are part air and part solid, such as the lungs. Flatness is heard over very dense tissue, such as the bone or muscle.
A gerontologic consideration of aging is the decreased ability to concentrate urine. This consideration leads to an increased susceptibility to dehydration further complicated by a deficit in thirst. Which nursing action would be most appropriate to address this concern?
- A. Encourage the client to decrease fluid intake.
- B. Instruct the client to double void.
- C. Offer the client use of the bathroom.
- D. Monitor the client for signs of drug toxicity.
Correct Answer: C
Rationale: A dull sound when percussing over the bladder indicates a full bladder. Because the bladder is full, the nurse would offer the client use of the bathroom. Tenderness over the kidney can indicate an infection or stones. Bruits are an abnormal vascular sound that does not indicate the need to use the bathroom. Ingesting water does not mean that the client has to void at this time.
The nurse is teaching a client about a urologic diagnostic procedure. Which teaching philosophy provides the best manner to present the information to the client?
- A. Stand beside the client and direct all information in the client's direction.
- B. Begin with the information most difficult to understand.
- C. Include humorous pictures to lighten the mood.
- D. Move from general details of the procedure to specifics.
Correct Answer: D
Rationale: Move from the general aspects such as purpose of the procedure to specifics including how the client will assist in the procedure. Doing so provides a foundation of knowledge and proceeds to more specific information. The client is more willing to participate when knowing the rationale. Standing beside the client, particularly if the client is in bed or seated, is a position of power. Humorous pictures do not convey the importance of the procedure or client participation.
The nurse is assisting the physician in completing a cystoscopy. In which position would the nurse place the client when preparing for the procedure?
- A. On the client's back with knees to the side
- B. On the client's back with feet in the stirrups
- C. On the client's right side with a pillow behind the back
- D. On the client's left side with a pillow behind the back
Correct Answer: B
Rationale: The client who is undergoing a cystoscopy will be positioned on the back with the feet in stirrups. The client is also to have an empty bladder and may be sedated for the procedure.
The nurse is instructing a 3-year-old's parent regarding abnormal findings within the urinary system. Which assessment finding would the nurse document as a normal finding for this age group?
- A. Dysuria
- B. Enuresis
- C. Hematuria
- D. Anuria
Correct Answer: B
Rationale: The nurse would be most correct to document that enuresis, the involuntary voiding during sleep or commonly called 'wetting the bed,' is a normal finding in a pediatric client younger than 5 years old. Dysuria (pain on urination), hematuria (red blood cell in urine), and anuria (urine output less than 50 mL/day) are all abnormal findings needing further investigation.