Nokea
The nurse is caring for a patient following rectal surgery who voids about 50 mL of urine every 30-60 minutes. Which of the following nursing actions is best?
- A. Use a bladder scan device to check the postvoiding residual.
- B. Monitor the patient's intake and output over the next few hours.
- C. Have the patient take small amounts of fluid frequently throughout the day.
- D. Reassure the patient that this is normal after rectal surgery because of anesthesia.
Correct Answer: A
Rationale: A bladder scan device can be used to check for residual urine after the patient voids. Because the patient's history and clinical manifestations are consistent with overflow incontinence, it is not appropriate to have the patient drink small amounts. Although overflow incontinence is not unusual after surgery, the nurse should intervene to correct the physiological problem, not just reassure the patient. The patient may develop reflux into the renal pelvis as well as discomfort from a full bladder if the nurse waits to address the problem for several hours.
You may also like to solve these questions
Which of the following actions should the nurse teach to a patient to help prevent the recurrence of renal calculi?
- A. Use a filter to strain all urine.
- B. Avoid dietary sources of calcium.
- C. Drink diuretic fluids such as coffee.
- D. Have 2000-3000 ml of fluid a day.
Correct Answer: D
Rationale: A fluid intake of 2000-2200 ml daily is recommended to help flush out minerals before stones can form. Avoidance of calcium is not usually recommended for patients with renal calculi. Coffee tends to increase stone recurrence. There is no need for a patient to strain all urine routinely after a stone has passed, and this will not prevent stones.
The nurse is assessing a patient who has a lower urinary tract infection (UTI). Which of the following symptoms should the nurse ask about initially?
- A. Nausea
- B. Flank pain
- C. Poor urine output
- D. Pain with urination
Correct Answer: D
Rationale: Pain with urination is a common symptom of a lower UTI. Urine output does not decrease, but frequency may be experienced. Flank pain and nausea are associated with an upper UTI.
The nurse is caring for a patient who has had a segmental cystectomy. Which of the following information should the nurse include in the postoperative teaching for the patient?
- A. Limit fluid intake for at least 7 days.
- B. Urine should be amber and not contain blood clots.
- C. In about one week urine will have rust-coloured flecks.
- D. Avoid sitz baths for a week after surgery.
Correct Answer: C
Rationale: Approximately 7-10 days following tumour resection or ablation, the patient may observe dark red or rust-coloured flecks in the urine. These are anticipated and represent scabs from the healing tumour resection sites. Other postoperative instructions for a segmental cystectomy include to drink a large volume of fluid each day for the first week following the procedure and to avoid intake of alcoholic beverages. Urine is anticipated to be pink during the first several days after the procedure, but it should not be bright red or contain blood clots. The patient can be encouraged to take a 15-20-minute sitz bath two to three times a day to promote muscle relaxation and to reduce the risk of urinary retention.
The nurse is caring for a young adult female patient who is diagnosed with polycystic kidney disease. Which of the following information should the nurse include in teaching at this time?
- A. Importance of genetic counselling
- B. Complications of renal transplantation
- C. Methods for treating persistent and severe pain
- D. Differences between hemodialysis and peritoneal dialysis
Correct Answer: A
Rationale: Because a young female patient may be considering having children, the nurse should include information about genetic counselling when teaching the patient. The well-managed patient will not need to choose between hemodialysis and peritoneal dialysis or know about the effects of transplantation for many years. There is no indication that the patient has persistent pain.
The nurse is assessing a male patient with symptoms of a feeling of incomplete bladder emptying and a split, spraying urine stream. Which of the following conditions should the nurse question the patient about when taking a health history?
- A. Bladder infection
- B. Recent kidney trauma
- C. Gonococcal urethritis
- D. Benign prostatic hyperplasia
Correct Answer: C
Rationale: The patient's clinical manifestations are consistent with urethral strictures, a possible complication of gonococcal urethritis. These symptoms are not consistent with benign prostatic hyperplasia, kidney trauma, or bladder infection.