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The nurse is caring for a patient who had a nephrectomy after having massive trauma to the kidney. Which of the following assessment findings obtained postoperatively is most important to communicate to the surgeon?
- A. Blood pressure is 102/58.
- B. Incisional pain level is 8/10.
- C. Urine output is 20 ml/hour for 2 hours.
- D. Crackles are heard at both lung bases.
Correct Answer: C
Rationale: Because the urine output should be at least 0.5 ml/kg/hour, a 20 ml output for 2 hours indicates that the patient may have decreased renal perfusion because of bleeding, inadequate fluid intake, or obstruction at the suture site. The blood pressure requires ongoing monitoring but does not indicate inadequate perfusion at this time. The patient should cough and deep breathe, but the crackles do not indicate a need for an immediate change in therapy. The incisional pain should be addressed, but this is not as potentially life-threatening as decreased renal perfusion.
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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.
The nurse is providing teaching to a patient with impaired urinary elimination related to an UTI who weighs 70 kg. Which of the following daily fluid intake amounts should the nurse include in the teaching plan?
- A. 650 mL
- B. 1250 mL
- C. 1800 mL
- D. 2450 mL
Correct Answer: C
Rationale: The recommended daily liquid intake for the ambulatory adult is approximately 30 mL/kg body weight per day. Thus, a 70-kg person would require approximately 2100 mL each day. Among the options, 1800 mL is the closest appropriate amount to promote adequate urine output and prevent UTI recurrence.
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.
The nurse is caring for a female patient who has had a urinary tract infection (UTI). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the patient to use a diaphragm for contraception.
- B. Sitz baths
- C. Encourage the patient to drink cranberry juice.
- D. Teach the patient how to do isometric perineal exercises.
Correct Answer: B
Rationale: Sitz baths can soothe the perineal area and promote voiding in patients with a UTI. Diaphragm use increases the risk for UTI and should be avoided. While cranberry juice may help prevent UTIs, evidence is inconclusive, and it is not a priority intervention. Isometric perineal exercises (e.g., Kegel exercises) are useful for stress incontinence, not UTI management.
The nurse is caring for a patient who has a history of functional urinary incontinence. Which of the following nursing actions should be included in the plan of care?
- A. Place a bedside commode near the patient's bed.
- B. Demonstrate the use of the Credé manoeuvre to the patient.
- C. Use an ultrasound scanner to check postvoiding residuals.
- D. Teach the use of Kegel exercises to strengthen the pelvic floor.
Correct Answer: A
Rationale: Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé manoeuvre are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.