Fundamentals Of Nursing NCLEX Quiz 13

1. Which statement indicates a need for further teaching of a home care client with a long term indwelling catheter?

“I will keep the collecting bag below the level of the bladder at all times”

“Intake of cranberry juice may help decrease the risk of infection”

“Soaking in a warm tub bath may ease the irritation associated with the catheter”

“I should use clean tech. when emptying the collecting bag”

Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (opt1). Intake of cranberry juice creates an environment nonconducive to infection (opt2). Clean technique is appropriate for touching the exterior portions of the system (opt4).

Explanation

Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (opt1). Intake of cranberry juice creates an environment nonconducive to infection (opt2). Clean technique is appropriate for touching the exterior portions of the system (opt4).

2. During shift report. the nurse learns that an older female client is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate?

Stress urinary incontinence

Reflex urinary incontinence

Functional urinary incontinence

Urge urinary incontinence

The key phrase is “the urge to void” option one occurs when the client coughs. sneezes. or jars the body. resulting in accidental loss of urine. Option two occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option three is involuntary loss of urine related to impaired function.

Explanation

The key phrase is “the urge to void” option one occurs when the client coughs. sneezes. or jars the body. resulting in accidental loss of urine. Option two occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option three is involuntary loss of urine related to impaired function.

3. The catheter slips into the vagina during a straight catheterization of a female client. The nurse does which action?

Leaves the catheter in place and gets a new sterile catheter

Leaves the catheter in place and asks another nurse to attempt the procedure

Removes the catheter and redirects it to the urinary meatus

Removes the catheter. wipes it with a sterile gauze. and redirects it to the urinary meatus

The catheter in the vagina is contaminated and can’t be reused.If left in place. it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn’t indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus (opt2).

Explanation

The catheter in the vagina is contaminated and can’t be reused.If left in place. it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn’t indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus (opt2).

4. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?

The bladder distends and its capacity increases

Older adults ignore the need to void

Urine becomes more concentrated

The amount of urine retained after voiding increases

The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (Option 4). Older adults don’t ignore the urge to void and may have difficulty getting to the toilet in time (Option 2). The kidney becomes less able to concentrate urine with age (Option3).

Explanation

The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (Option 4). Older adults don’t ignore the urge to void and may have difficulty getting to the toilet in time (Option 2). The kidney becomes less able to concentrate urine with age (Option3).

5. Which action represents the appropriate nursing management of a client wearing a condom catheter?

Ensure that the tip of the penis fits snugly against the end of the condom

Check the penis for adequate circulation 30 min after applying

Change the condom every 8 hours

Tape the collecting tube to the lower abdomen.

The penis and condom should be checked 1/2 hour after application to ensure that it’s not too tight. A 1 in. space should be left btw the penis and the end of the condom (opt1). The condom is changed every 24h (opt3) and the tubing is taped to the leg or attached to a leg bag. An indwelling catheter is taped to the lower abdomen or upper thigh (opt4).

Explanation

The penis and condom should be checked 1/2 hour after application to ensure that it’s not too tight. A 1 in. space should be left btw the penis and the end of the condom (opt1). The condom is changed every 24h (opt3) and the tubing is taped to the leg or attached to a leg bag. An indwelling catheter is taped to the lower abdomen or upper thigh (opt4).

6. A female client has a urinary tract infection. Which teaching points by the nurse should be helpful to the client? Select all that apply.

Limit fluids to avoid the burning sensation on urination

Review symptoms of UTI with the client

Wipe the perineal area from back to front

Wear cotton underclothes

Take baths rather than showers

Option two validates the diagnosis. Cotton underwear promotes appropriate exposure to air. resulting in decreased bacterial growth (opt4). Increased fluids decrease concentration and irritation (opt1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (opt3). Showers reduce exposure of area to bacteria (opt5).

Explanation

Option two validates the diagnosis. Cotton underwear promotes appropriate exposure to air. resulting in decreased bacterial growth (opt4). Increased fluids decrease concentration and irritation (opt1). The client should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (opt3). Showers reduce exposure of area to bacteria (opt5).

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7. The nurse will need to assess the client's performance of clean intermittent self catheterization (CISC) for a client with which urinary diversion?

Ileal conduit

Kock pouch

Neobladder

Vesicostomy

The ileal conduit and vesicostomy (opt1.4) are in continent urinary diversions. and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (opt3).

Explanation

The ileal conduit and vesicostomy (opt1.4) are in continent urinary diversions. and clients are required to use an external ostomy appliance to contain the urine. Clients with a neobladder can control their voiding (opt3).

8. Which focus is the nurse most likely to teach for a client with a flaccid bladder?

Habit training: attempt voiding at specific time periods

Bladder training: delay voiding according to a pre-schedule timetable

Crede’s maneuver: apply gentle manual pressure to the lower abdomen

Kegel exercises: contract the pelvic muscles

Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination. the process is initiated manually. Options one. two. and four: to promote continence bladder contractions are required for habit training. bladder training. and increasing the tone of the pelvic muscles.

Explanation

Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination. the process is initiated manually. Options one. two. and four: to promote continence bladder contractions are required for habit training. bladder training. and increasing the tone of the pelvic muscles.

9. During assessment of the client with urinary incontinence. the nurse is most likely to assess for which of the following? Select all that apply.

Perineal skin irritation

Fluid intake of less than 1.500 mL/d

History of antihistamine intake

Hx of UTI

A fecal impaction

The perineum may become irritated by the frequent contact with urine (Opt1). Normal fluid intake is at least 1.500 mL/d and clients often decrease their intake to try to minimize urine leakage (Opt2). UTIs can contribute to incontinence (Opt4). A fecal impaction can compress the urethra. which results in sm. amts of urine leakage (Opt5). Antihistamines can cause urinary retention rather than urinary incontinence (Opt3).

Explanation

The perineum may become irritated by the frequent contact with urine (Opt1). Normal fluid intake is at least 1.500 mL/d and clients often decrease their intake to try to minimize urine leakage (Opt2). UTIs can contribute to incontinence (Opt4). A fecal impaction can compress the urethra. which results in sm. amts of urine leakage (Opt5). Antihistamines can cause urinary retention rather than urinary incontinence (Opt3).

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10. Which of the following behaviors indicates that the client on a bladder training program has met the expected outcomes? Select all that apply.

Voids each time there is an urge

Practices slow. deep breathing until the urge decreases

Uses adult diapers. for “just in case”

Drinks citrus juices and carbonated beverages

Performs pelvic muscle exercises

It is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Some clients may need diapers; this is not the best indicator of a successful program (opt3). Citrus juices may irritate the bladder (opt4). Carbonated beverages increase diuresis and the risk of incontinence (opt4).

Explanation

It is important for the client to inhibit the urge to void sensation when a premature urge is experienced. Some clients may need diapers; this is not the best indicator of a successful program (opt3). Citrus juices may irritate the bladder (opt4). Carbonated beverages increase diuresis and the risk of incontinence (opt4).

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