Fundamentals Of Nursing NCLEX Quiz 14

2.

A patient’s urine is cloudy. is amber. and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment?

Urinary retention
Urinary tract infection
Ketone bodies in the urine
High urinary calcium level

Correct Answer

A. Urinary tract infection

Explanation

The urine appears concentrated (amber)and cloudy because of the presence of bacteria. white blood cells. and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria). These clinical manifestations do not reflect urinary retention. Urinary retention is evidenced by supra pubic distention and lack of voiding or small. frequent voiding (overflow incontinence) (opt1). These clinical manifestations do not reflect Ketone bodies in the urine. A reagent strip dipped in urine will measure the presence of Ketone bodies (opt3). These clinical manifestations do not reflect excessive calcium in the urine. Urine calcium levels are measured by assessing a 24 hour urine specimen (opt4).

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3.

A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen?

Use a sterile specimen container.
Collect urine from the catheter port.
Inflate the balloon with 10 mL of sterile water.
Have the patient void before collecting the specimen.

Correct Answer

A. Use a sterile specimen container.

Explanation

A culture attempts to identify the microorganisms present in the urine. and a sensitivity study identifies the antibiotics that are effective against the isolated micro organisms. A sterile specimen container is used to prevent contamination of the specimen by micro organisms outside the body (exogenous). The urine from straight catheter flows directly into the specimen container. Collecting a urine specimen from a catheter port is necessary when the patient has a urinary retention catheter (opt2). A straight catheter has a single lumen for draining urine from the bladder. A straight catheter does not remain in the bladder and therefore does not have a 2nd lumen for water to be inserted into a balloon (opt3). This may result in no urine left in the bladder for the straight catheter to collect. A minimum of 3 mL of urine is necessary for a specimen for urine culture and sensitivity (opt4).

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4.

A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation?

Coughing
Mobility deficits
Prostate enlargement
Urinary tract infection

Correct Answer

A. Prostate enlargement

Explanation

An enlarged prostate compresses the urethra and interferes with the outflow of urine. resulting in urinary retention. With urinary retention. the pressure within the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25-60mL) of urine to escape (overflow incontinence). Coughing. which raises the intro abdominal pressure. is related to stress incontinence. not overflow incontinence (opt1). Mobility deficits. such as spinal cord injuries. are related to reflex incontinence. not overflow incontinence (opt2). Urinary tract infections are related to urge incontinence. not overflow incontinence (opt4).

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1

5.

A provider prescribes a 24 hour urine collection for a client. Which of the following actions should the nurse take?

Discard the first voiding
Keep all voidings in a container at room temperature
Ask the client to urinate and pour the urine into a specimen container
Ask the client to urinate into the toilet. stop midstream. and finish urinating into the specimen container

Correct Answer

A. Discard the first voiding

Explanation

The nurse should discard the first voiding of the 24 hour urine specimen. and note the time. The nurse should collect all voidings after that and keep them in a refrigerated container (opt2). For a urinalysis. the nurse should ask the client to urinate and pour the urine into a specimen container (opt3). For a culture. the nurse should ask the client to urinate first into the toilet. then stop midstream. and finish urinating in the specimen container (opt4).

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6.

A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient’s needs?

Encouraging the use of bladder training exercises
Providing assistance with toileting every four hours
Positioning a bedside commode near the bed
Teaching the avoidance of fluid after 5 PM

Correct Answer

A. Positioning a bedside commode near the bed

Explanation

The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on the commode uses gravity to empty the bladder fully and thus prevent urinary stasis. Although option 1 should be done. it is not the priority. Option 2 may be too often or not often enough for the patient. Care should be individualized for the patient. Fluids may be decreased during the last two hours before bedtime. but they should not be avoided completely after 5 PM (opt4). Some fluid intake is necessary for adequate renal perfusion.

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7.

A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter?

Urinal
Graduate
Large syringe
Urine collection bag

Correct Answer

A. Graduate

Explanation

A graduate is a collection container with volume markings usually at 25 mL increments that promote accurate measurements of urine volume. Although urinals have volume markings on the side. usually they occur in 100 mL increments that do not promote accurate measurements (opt1). Option 3 is impractical. A large syringe is used to obtain a sterile specimen from a retention catheter (Foley catheter). A urine collection bag is flexible and balloons outward as urine collects. In addition. the volume markings are at 100 mL increments that do not promote accurate measurements (opt4).

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8.

A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections with a group of assistive personnel. Which of the following should be included in the review? Select all that apply.

Having sexual intercourse on a frequent basis
Lowering of testosterone levels
Wiping from front to back
The location of the vagina in relation to the anus
Undergoing frequent catheterization

Correct Answer(s)

A. Having sexual intercourse on a frequent basis
A. The location of the vagina in relation to the anus
A. Undergoing frequent catheterization

Explanation

Having sexual intercourse on a frequent basis is a factor that increases the risk of UTI in both males and females. The close proximity of the female urethra to the anus is a factor that increases the risk of UTIs. Undergoing frequent catheterization and the use of indwelling catheters are risk factors for UTIs. The decrease in estrogen levels during menopause increases a woman’s susceptibility to UTIs (opt2). Wiping from front to back decreases a woman’s risk of UTIs (opt3).

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1

9.

A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? Select all that apply.

Establish a schedule of voiding prior to meal times
Have the client record voiding times
Gradually increase the voiding intervals
Reminded client to hold urine until next scheduled voiding time
Provide a sterile container for voiding

Correct Answer(s)

A. Have the client record voiding times
A. Gradually increase the voiding intervals
A. Reminded client to hold urine until next scheduled voiding time

Explanation

Ask the client to keep track of voiding times is an appropriate nursing action. Gradually increasing the voiding interval is an appropriate nursing action. The client should be reminded to hold urine until the next scheduled voiding time. Bladder training involves voiding at scheduled in frequent intervals and gradually increasing these intervals to four hours. Mealtimes are not regular. and the intervals may be longer than every four hours (opt1). A sterile container is not used in a bladder training program (opt5).

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10.

A nurse in a provider’s office is assessing a client who reports losing control of urine when ever she coughs. laughs. or sneezes. The client relates a history of three vaginal births. but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to control or eliminate the clients incontinence? Select all that apply.

Limit total daily fluid intake
Decrease or avoid caffeine
Increase the intake of calcium supplements
Avoid the intake of alcohol
Use Crede maneuver

Correct Answer(s)

A. Decrease or avoid caffeine
A. Increase the intake of calcium supplements

Explanation

Caffeine and alcohol are bladder irritants and can worsen stress incontinence. Alcohol is a bladder irritant and can worsen stress incontinence. Because stress incontinence results from weak pelvic muscles and other structures. limiting fluid will not resolve the problem (opt1). Calcium has no effect on stress incontinence (opt3). The Crede maneuver helps manage reflex incontinence. not stress incontinence (opt5).

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Fundamentals Of Nursing NCLEX Quiz 14

A client who has an indwelling catheter reports I need to urinate. Which of the following interventions should the nurse perform?

Quiz Preview

A patient’s urine is cloudy. is amber. and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment?

A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen?

A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation?

A provider prescribes a 24 hour urine collection for a client. Which of the following actions should the nurse take?

A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient’s needs?

A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter?

A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections with a group of assistive personnel. Which of the following should be included in the review? Select all that apply.

A nurse is preparing to initiate a bladder training program for a client who has a voiding disorder. Which of the following actions should the nurse take? Select all that apply.