Nokea
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.
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Examination of a client's bladder stones reveal that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?
- A. Low oxalate
- B. Low purine
- C. High protein
- D. High sodium
Correct Answer: B
Rationale: A low-purine diet is used for uric acid stones, the benefits, however, are unknown. Clients with a history of calcium oxalate stone formation need a diet that is adequate in calcium and low in oxalate. Only clients who have type II absorptive hypercalciumâ??approximately half of the clientsâ??need to limit calcium intake. Usually, clients are told to increase their fluid intake significantly, consume a moderate protein intake, and limit sodium. Avoiding excessive protein intake is associated with lower urinary oxalate and lower uric acid levels. Reducing sodium intake can lower urinary calcium levels.
The best nursing action to remove urine from the bladder is to use a curve-tipped coud?© catheter
- A. Use a large catheter such as a 22 French
- B. Use a straight-tipped catheter
- C. Crec?º maneuver
Correct Answer: C
Rationale: The best nursing action to remove urine from the bladder is to use a curve-tipped coud?© catheter. The coud?© catheter has a curved tip to slide over the obstruction. Using a large catheter such as a 22 French would meet resistance and traumatize the urethral lining. A straight-tipped catheter also would meet the obstruction and not advance. Crec?º maneuver may eliminate a small amount of urine but does nothing to allow urine flow around the narrowing.
The nurse is caring for several clients on a urinary medical unit. Which client is at an increased risk for bladder stones?
- A. The client with frequent urinary tract infections
- B. The client who is paraplegic
- C. The client with difficulty ambulating
- D. The client with abdominal surgery
Correct Answer: B
Rationale: The client who is immobile or who is paraplegic may also tend to form bladder stones. Clients with incomplete urinary elimination, urinary stasis, or concentrated urine are at higher risk for stone formation. There is not as strong correlation between infections, difficulty ambulating, and surgery.
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.
The following catheterization procedures are used to treat clients with urinary retention. Which procedure would the nurse identify as carrying the greatest risk to the client?
- A. Supurapubic cystostomy tube
- B. Permanent drainage with a urethral catheterer
- C. Clean intermittent catheterization
- D. Cred?© voiding procedure
Correct Answer: B
Rationale: Permanent drainage with a urethral catheter carries the greatest risk. It may also increase the risk for bladder stones; renal diseases; bladder infections; and urosepsis, a severe systemic infection by microorganisms in the urinary tract invading the bloodstream. Clean intermittent catheterization has the fewest complications and is the preferred treatment for urinary retention. The Cred?© voiding procedure is used in the case of clients who have lost control over their nervous systems, secondary to injury or disease.