Urinary System Disorders | NCLEX Quiz 113

1. A female client with a urinary diversion tells the nurse. "This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore." The most appropriate nursing diagnosis for this patient is:

Anxiety related to the presence of urinary diversion.

Deficient Knowledge about how to care for the urinary diversion.

Low Self-Esteem related to feelings of worthlessness

Disturbed Body Image related to creation of a urinary diversion.

It is normal for clients to express fears and concerns about the body changes associated with a urinary diversion. Allowing the client time to verbalize concerns in a supportive environment and suggest that she discuss these concerns with people who have successfully adjusted to ostomy surgery can help her begin coping with these changes in a positive manner.Options A and C: Although the client may be anxious about this situation and self-esteem may be diminished. the underlying problem is a disturbance in body image.Option B: There are no data to support a diagnosis of Deficient Knowledge.

Explanation

It is normal for clients to express fears and concerns about the body changes associated with a urinary diversion. Allowing the client time to verbalize concerns in a supportive environment and suggest that she discuss these concerns with people who have successfully adjusted to ostomy surgery can help her begin coping with these changes in a positive manner.Options A and C: Although the client may be anxious about this situation and self-esteem may be diminished. the underlying problem is a disturbance in body image.Option B: There are no data to support a diagnosis of Deficient Knowledge.

2. The nurse teaches the client with an ileal conduit measures to prevent a UTI. Which of the following measures would be most effective?

Avoid people with respiratory tract infections

Maintain a daily fluid intake of 2.000 to 3.000 ml

Use sterile technique to change the appliance

Irrigate the stoma daily.

Maintaining a fluid intake of 2.000 to 3.000 ml/day is likely to be effective in preventing UTI. A high fluid intake results in high urine output. which prevents urinary stasis and bacterial growth.Option A: Avoiding people with respiratory tract infections will not prevent urinary tract infections.Option C: Clean. not sterile. technique is used to change the appliance.Option D: An ileal conduit stoma is not irrigated.

Explanation

Maintaining a fluid intake of 2.000 to 3.000 ml/day is likely to be effective in preventing UTI. A high fluid intake results in high urine output. which prevents urinary stasis and bacterial growth.Option A: Avoiding people with respiratory tract infections will not prevent urinary tract infections.Option C: Clean. not sterile. technique is used to change the appliance.Option D: An ileal conduit stoma is not irrigated.

3. Which of the following interventions would be most appropriate for preventing the development of a paralytic ileus in a client who has undergone renal surgery?

Encourage the client to ambulate every 2 to 4 hours

Offer 3 to 4 ounces of a carbonated beverage periodically.

Encourage use of a stool softener

Continue intravenous fluid therapy

Ambulation stimulates peristalsis. A client with paralytic ileus is kept NPO until peristalsis returns.Option C: A stool softener will not stimulate peristalsis.Option D: Intravenous fluid infusion is a routine postoperative order that does not have any effect on preventing paralytic ileus.

Explanation

Ambulation stimulates peristalsis. A client with paralytic ileus is kept NPO until peristalsis returns.Option C: A stool softener will not stimulate peristalsis.Option D: Intravenous fluid infusion is a routine postoperative order that does not have any effect on preventing paralytic ileus.

4. The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with what product?

Baking soda

Soap

Hydrogen peroxide

Alcohol

A reusable appliance should be routinely cleaned with soap and water.

Explanation

A reusable appliance should be routinely cleaned with soap and water.

5. A client has a ureteral catheter in place after renal surgery. A priority nursing action for care of the ureteral catheter would be to:

Irrigate the catheter with 30 ml of normal saline every 8 hours

Ensure that the catheter is draining freely

Clamp the catheter every 2 hours for 30 minutes.

Ensure that the catheter drains at least 30 ml an hour

The ureteral catheter should drain freely without bleeding at the site.Option A: The catheter is rarely irrigated. and any irrigation would be done by the physician.Option C: The catheter is never clamped.Option D: The client’s total urine output (ureteral catheter plus voiding or Foley catheter output) should be 30 ml/hour.

Explanation

The ureteral catheter should drain freely without bleeding at the site.Option A: The catheter is rarely irrigated. and any irrigation would be done by the physician.Option C: The catheter is never clamped.Option D: The client’s total urine output (ureteral catheter plus voiding or Foley catheter output) should be 30 ml/hour.

6. A client who has been diagnosed with calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time?

Report hematuria to the physician

Strain the urine carefully

Administer meperidine (Demerol) every 3 hours

Apply warm compresses to the flank area

Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement. and the urine should be strained to detect the passage of the stone.Option A: Hematuria is to be expected from the irritation of the stone.Option C: Analgesics should be administered when the client needs them. not routinely.Option D: Moist heat to the flank area is helpful when renal colic occurs. but it is less necessary as pain is lessened.

Explanation

Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement. and the urine should be strained to detect the passage of the stone.Option A: Hematuria is to be expected from the irritation of the stone.Option C: Analgesics should be administered when the client needs them. not routinely.Option D: Moist heat to the flank area is helpful when renal colic occurs. but it is less necessary as pain is lessened.

7. The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the assessment data. which of the following nursing interventions would be most appropriate at this time?

Change the appliance bag

Notify the physician

Obtain a urine specimen for culture

Encourage a high fluid intake

Mucus is secreted by the intestinal segment used to create the conduit and is a normal occurrence. The client should be encouraged to maintain a large fluid intake to help flush the mucus out of the conduit.Option A: Because mucus in the urine is expected. it is not necessary to change the appliance bag or notify the physician.Option C: The mucus is not an indication of an infection. so a urine culture is not necessary.

Explanation

Mucus is secreted by the intestinal segment used to create the conduit and is a normal occurrence. The client should be encouraged to maintain a large fluid intake to help flush the mucus out of the conduit.Option A: Because mucus in the urine is expected. it is not necessary to change the appliance bag or notify the physician.Option C: The mucus is not an indication of an infection. so a urine culture is not necessary.

8. When teaching the client to care for an ileal conduit. the nurse instructs the client to empty the appliance frequently. primarily to prevent which of the following problems?

Rupture of the ileal conduit

Interruption of urine production

Development of odor

Separation of the appliance from the skin

If the appliance becomes too full. it is likely to pull away from the skin completely or to leak urine onto the skin. A full appliance will not rupture the ileal conduit or interrupt urine production. Odor formation has numerous causes.

Explanation

If the appliance becomes too full. it is likely to pull away from the skin completely or to leak urine onto the skin. A full appliance will not rupture the ileal conduit or interrupt urine production. Odor formation has numerous causes.

9. The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent:

Urine reflux into the stoma

Appliance separation

Urine leakage

The need to restrict fluids

The most important reason for attaching the appliance to a standard urine collection bag at night is to prevent reflux into the stoma and ureters. which can result in infection.Options B and C: Use of a standard collection bag also keeps the appliance from separating from the skin and helps prevent urine leakage from an overly full bag. but the primary purpose is to prevent reflux of urine.Option D: A client with a urinary diversion should drink 2000-3000 ml of fluid each day; it would be inappropriate to suggest decreasing fluid intake.

Explanation

The most important reason for attaching the appliance to a standard urine collection bag at night is to prevent reflux into the stoma and ureters. which can result in infection.Options B and C: Use of a standard collection bag also keeps the appliance from separating from the skin and helps prevent urine leakage from an overly full bag. but the primary purpose is to prevent reflux of urine.Option D: A client with a urinary diversion should drink 2000-3000 ml of fluid each day; it would be inappropriate to suggest decreasing fluid intake.

10. The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.

“If I limit my fluid intake I will not have to empty my ostomy pouch as often.”

“I can place an aspirin tablet in my pouch to decrease odor.”

“I can usually keep my ostomy pouch on for 3 to 7 days before changing it.”

“I must use a skin barrier to protect my skin from urine.”

“I should empty my ostomy pouch of urine when it is full.”

The client with an ileal conduit must learn self-care activities related to the care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3.000 ml per day and should not limit intake. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine.Option A: Adequate fluid intake helps to flush mucus from the ileal conduit.Option B: An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration.Option E: The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

Explanation

The client with an ileal conduit must learn self-care activities related to the care of the stoma and ostomy appliances. The client should be taught to increase fluid intake to about 3.000 ml per day and should not limit intake. The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. A skin barrier is essential to protecting the skin from the irritation of the urine.Option A: Adequate fluid intake helps to flush mucus from the ileal conduit.Option B: An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration.Option E: The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight from pulling the appliance away from the skin.

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