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The nurse is caring for a client who is following a treatment plan to decrease urinary tract infections. What indicates the need to change the treatment plan?
- A. The client has history of repeated antibiotic therapy
- B. The client has improved personal hygiene methods
- C. The client exhibits continued symptoms
- D. The client has diluted urine
Correct Answer: C
Rationale: If the client exhibits continued symptoms, the treatment plan is ineffective and the plan needs to be revised. Having a history of antibiotic therapy indicates the need to establish a treatment plan. Having improved hygiene indicates that the client is following the treatment plan. Having diluted urine indicates that the client has increased fluids which are a plan of typical treatment plans.
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The nurse is encouraging the client with recurrent urinary tract infections to increase fluid intake to 8 large glasses of fluids daily. Which beverage would the nurse discourage for this client?
- A. Coffee in the morning
- B. Fruit juice midmorning
- C. Milk at lunch
- D. Ginger ale at dinner time
Correct Answer: A
Rationale: The nurse would discourage drinking coffee. Coffee, tea, alcohol, and colas are urinary tract irritants. Fruit juice, milk, and ginger ale are appropriate for drinking and counted toward the daily fluid total.
The nurse is caring for a client for whom an ileal conduit is created after a radical cystectomy. Which instructions would the nurse expect to include in the client's plan of care?
- A. Application of an ostomy pouch
- B. Intermitient catheterizations
- C. Exercises to promote sphincter control
- D. Irrigating the urinary diversion
Correct Answer: A
Rationale: An ileal conduit involves care of a urinary stoma, much like that of a fecal stoma, including the application of an ostomy pouch, skin protection, and stoma care. Intermitient catheterizations and irrigations are appropriate for a continent urinary diverse such as a Kock or Indiana pouch. Exercises to promote sphincter control are appropriate for an ureterosigmoidoscopy.
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.
The nurse is completing a plan of care for a client with chronic urinary incontinence. Which of the following outcomes is a priority?
- A. The client will decrease fluid intake to 1000 mL/day
- B. The client will use the bathroom every 30 minutes while awake
- C. The client will maintain perineal skin integrity
- D. The client will express feelings of acceptance related to condition
Correct Answer: C
Rationale: The nurse planning care would identify the priority outcome being to maintain skin integrity. Due to the urinary incontinence, perineal skin breakdown may occur due to the warm, moist environment. A skin barrier or moisture sealant is suggested. The nurse would not decrease fluid intake dramatically or tell the client to use the bathroom every 30 minutes in a chronic condition. It is important to accept those things that cannot be controlled.
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.