Urinary Elimination: Q&A for Nursing Students, Exams of Nursing

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Unit 11, Chapter 46 - Urinary Elimination

Q&A

anuria - Correct Answers: failure of kidney to produce urine catheter - Correct Answers: tube placed through urethra into bladder to drain urine condom catheter - Correct Answers: a soft, pliable condom-like sheath that fits over the penis, providing a safe and non-invasive way to contain urine cystoscopy - Correct Answers: a procedure that allows provider to examine the lining of bladder and urethra; a hollow tube equipped with a lens is inserted through urethra and slowly advanced into bladder dysuria - Correct Answers: burning or pain with urination enuresis - Correct Answers: involuntary urination foley catheter - Correct Answers: flexible tube passed through the urethra and into the bladder to drain urine; most common type of indwelling urinary catheter frequency - Correct Answers: voiding more than 8 times during waking hours and/or at decreased intervals such as less than every 2 hours functional incontinence - Correct Answers: loss of continence from causes outside the urinary tract; usually related to functional deficits such as altered mobility and manual dexterity, cognitive impairment, or environmental barriers glycosuria - Correct Answers: excess of sugar in the urine, typically associated with diabetes or kidney disease hematuria - Correct Answers: blood in the urine incontinence - Correct Answers: lack of voluntary control over urination or defecation

total incontinence - Correct Answers: continuous and total loss of urinary control and is the severest type of incontinence; causes either continuous leakage or periodic, uncontrolled emptying of the bladder's contents; bladder becomes incapable of storing any urine urge incontinence - Correct Answers: involuntary passage of urine often associated with a strong sense of urgency related to overactive bladder (caused by neuro problems, bladder inflammation or obstruction); in many cases bladder overactivity is idiopathic (cause unknown); caused by involuntary contractions of the bladder associated with an urge to void that causes leakage of urine urgency - Correct Answers: an immediate and strong desire to void that is not easily deferred urinary incontinence - Correct Answers: complaint of any involuntary loss of urine urinary retention - Correct Answers: inability to partially or completely empty the bladder urination - Correct Answers: the discharge of urine from the body voiding - Correct Answers: the discharge of urine from the body; another way to say urination or micturition Review basic anatomy and physiology of the urinary tract. - Correct Answers: Kidneys

• nephrons - function unit of the kidneys that remove waste products from the blood and play a major role in the regulation of fluid and electrolyte balance
• glomerulus - each nephron contains a cluster of capillaries called the glomerulus; filters water, glucose, amino acids, urea, uric acid, creatinine, and major electrolytes; large proteins and blood cells don't filter through the glomerulus
• proximal convoluted tubule, loop of Henle, distal tubule- approximately 99% of glomerular filtrate is resorbed into the plasma by the proximal convoluted tubule, the loop of Henle and the distal tubule Ureters
• attached to each kidney pelvis and carries urinary waste to the bladder Bladder
• a hollow, distensible, muscular organ that holds urine; expands as it fills with urine

Urethra

• urine travels from the bladder through the urethra and passes to the outside of the body through the urethral meatus Pg. 1101 - 1103 Define micturition, voiding and urination. - Correct Answers: all terms that describe the process of the bladder emptying Describe factors influencing urination. - Correct Answers: Growth and development Sociocultural factors Psychological factors Personal habits Fluid intake Pathological conditions Surgical procedures Medications Diagnostic examinations Pg. 1102 Box 46- Describe key signs and symptoms of urinary retention. - Correct Answers: Acute or rapid:
• Feelings of pressure, discomfort/pain, tenderness over the symphysis pubis, restlessness and sometimes diaphoresis (sweating)
• Patients may have no urine output over several hours and in some cases experience frequency, urgency, small-volume voiding or incontinence of small volumes of urine Chronic:
• slow, gradual onset, decrease in voiding volumes, straining to void, frequency, urgency, incontinence and sensations of incomplete emptying Pg. 1103 Identify assessments for urinary retention. - Correct Answers: Palpate the bladder for smooth, rounded mass

Identify nursing diagnosis for patients with urinary elimination problems from established nursing diagnosis list. - Correct Answers: Functional urinary incontinence Stress urinary incontinence Urge urinary incontinence Reflex incontinence Risk for infection Toileting self-care deficit Impaired skin integrity Impaired urinary elimination Urinary retention Pg. 1113 Compare and contrast common urinary alterations. - Correct Answers: Urgency - overactive bladder, UTI, full bladder, inflammation or irritation of bladder Dysuria - UTI, inflammation of the prostate, urethritis, trauma to the lower urinary tract, urinary tract tumors Frequency - overactive bladder, UTI, high volumes of fluid intake, bladder irritants, increased pressure on the bladder Hesitancy - bladder outlet obstruction, anxiety Polyuria - high volumes of fluid intake, uncontrolled diabetes mellitus, diabetes insipidus, diuretic therapy Oliguria - fluid and electrolyte imbalance, kidney dysfunction or failure, increase secretion of ADH, urinary tract obstruction Nocturia - overactive bladder, bladder outlet obstruction, UTI, medications, cardiovascular disease Dribbling - bladder outlet obstruction, incomplete bladder emptying, stress incontinence Hematuria - tumors, infection, trauma to urinary tract, urinary tract calculi Retention - bladder outlet obstruction, absent or weak bladder contractility, side effects of certain meds Pg. 1110 Table 46-

Identify the most common causes of UTIs. - Correct Answers: E. coli is most common causative pathogen. Risk increases in the presence of an indwelling catheter, any instrumentation of the urinary tract, urinary retention, urinary and fecal incontinence and poor perineal hygiene practices. CAUTIs are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stays and increased hospital costs. Pg. 1103, 1105 Establish goals for identified urinary elimination problems. - Correct Answers: Must include realistic and individualized goals along with relevant outcomes. A general goal is often normal urinary elimination; but sometimes the individual goal differs, depending on the problem. Pg. 1115 Describe the guidelines for nursing interventions to maintain normal elimination. - Correct Answers: Box 46- Pg. 1104 Identify nursing interventions to promote micturition and reduce episodes of incontinence. - Correct Answers: Adequate lighting in bathroom. Individualized toileting program. Mobility aides (raised toilet set, toilet grab bars) Elastic waist pants without buttons or zippers Call bell always in reach Avoid bladder irritants Instruct patient in pelvic muscle exercises, as directed by healthcare provider. Monitor for s/s of UTI or urinary retention. Pg. 1104 Table 46- Explain the procedure for application and removing a condom catheter. - Correct Answers: Identify patient with two identifiers. Perform hand hygiene.

• make sure catheter isn't leaking from catheter, tubing or connections
• assess urine character and amount of urine in drainage system
• evaluate patient for s/s of UTI - pain, burning, discomfort, irritation
• assess self-care skills
• have patient discuss feelings regarding permanent changes in elimination
• assess external genitalia for inflammation/infection
• assess urinary meatus for catheter related damage, inflammation and discharge - early detection of trauma Pgs. 1111, 1121, 1127, 1139 Identify nursing interventions used to prevent catheter urinary infections. - Correct Answers: Require use of evidence based "bundle" to perform all elements of care at one time along with completion of a checklist to ensure that each element is included in that care. Know institutions policies. Patients in acute care hospital should have urinary catheters inserted using aseptic technique with sterile equipment. Secure indwelling catheters to prevent movement and pulling on the catheter. Maintain a closed urinary drainage system. Maintain an unobstructed flow of urine through the catheter, drainage tubing and drainage bag. Keep the urinary drainage bag below the level of the bladder at all times. Avoid dependent loops in urinary drainage tubing. Prevent the urinary drainage bag from touching or dragging on the floor. When emptying the urinary drainage bag, use a separate measuring receptacle for the patient. Don't let the drainage spigot touch the receptacle. Before transfers or activity, drain all urine from the tubing into bag and empty drainage bag. Empty the drainage bag when ½ full. Perform routine perineal hygiene daily and after soiling using antiseptic wipes. Be sure to use a wipe to clean the length of the exposed catheter. Obtain urine samples using the sampling port. Cleanse the port with disinfectant. Use a sterile syringe/cannula. Quality improvement programs should be in place that alert providers that a catheter is in place and include regular educational programming about catheter care. Pg. 1122 Box 46-

Identify the guidelines for bladder retraining. - Correct Answers: Patients are given a toileting schedule on the basis of their diary of voiding and leaking and it's designed to slowly increase the interval between voiding. Patients are taught to inhibit the urge to void by taking slow, deep breaths to relax, performing five to six quick, strong pelvic muscle exercises (flicks) in quick succession, followed by distracting attention from bladder sensations. When the urge to void becomes less sever or subsides, only then should the patient start his or her trip to the bathroom. Pgs. 1126, 1127 Describe techniques used in providing bedpan, urinal or commode. - Correct Answers: A strategy to promote relaxation and stimulate bladder contractions is to help patients assume the normal position for voiding. Depending on the patient, more assistance is needed (ie, placing the penis in the urinal). Use sensory stimuli and provide privacy to promote relaxation and stimulate bladder contractions. Bladder exercises help to improve pelvic muscles, which reduces stress incontinence and improves bladder emptying. Pg. 1119 Describe outcome criteria for patients with urinary problems. - Correct Answers: Evaluate for changes in the patient's voiding pattern and/or presence of symptoms such as dysuria, urinary retention and UI. Evaluate patient/caregiver compliance with the plan such as toileting according to the schedule or the number of incontinent episodes. Actual outcomes are compared with expected outcomes to determine success or partial success in achieving these outcomes. Pg. 1127 A patient is scheduled to have an intravenous pyelogram (IVP) the next morning. Which nursing measures should be implemented before the test? (Select all that apply.)

1. Ask the patient about any allergies and reactions.
2. Instruct the patient that a full bladder is required for the test.
3. Instruct the patient to save all urine in a special container.
4. Ensure that informed consent has been obtained.
5. Explain that the test includes instrumentation of the urinary tract. - Correct Answers: Answer: 1, 4 When assessing a patient's first voided urine of the day, which finding should be reported to the health care provider?

4. Assess vital signs. - Correct Answers: Answer: 2 An ambulatory elderly woman with dementia is incontinent of urine. She has poor short-term memory and has not been seen toileting independently. What is the best nursing intervention for this patient?
5. Recommend that she be evaluated for an overactive bladder (OAB) medication.
6. Start a scheduled toileting program.
7. Recommend that she be evaluated for an indwelling catheter.
8. Start a bladder-retraining program. - Correct Answers: Answer: 2 What should the nurse teach a young woman with a history of urinary tract infections (UTIs) about UTI prevention? (Select all that apply.)
9. Keep the bowels regular.
10. Limit water intake to 1 to 2 glasses a day.
11. Wear cotton underwear.
12. Cleanse the perineum from front to back.
13. Practice pelvic muscle exercise (Kegel) daily. - Correct Answers: Answer: 1, 3, 4 Which nursing assessment question would best indicate that an incontinent man with a history of prostate enlargement might not be emptying his bladder adequately?
14. Do you leak urine when you cough or sneeze?
15. Do you need help getting to the toilet?
16. Do you dribble urine constantly?
17. Does it burn when you pass urine? - Correct Answers: Answer: 3 Place the following steps for insertion of an indwelling catheter in a female patient in appropriate order.
18. Insert and advance catheter.
19. Lubricate catheter.
20. Inflate catheter balloon.
21. Cleanse urethral meatus with antiseptic solution.
22. Drape patient with the sterile square and fenestrated drapes.

6. When urine appears, advance another 2.5 to 5 cm.
7. Prepare sterile field and supplies.
8. Gently pull catheter until resistance is felt.
9. Attach drainage tubing. - Correct Answers: Answer: 5, 7, 2, 4, 1, 6, 3, 8, 9 The nursing assistive personnel (NAP) reports to the nurse that a patient's catheter drainage bag has been empty for 4 hours. What is a priority nursing diagnosis?
10. Implement the "as-needed" order to irrigate the catheter.
11. Assess the catheter and drainage tubing for obvious occlusion.
12. Notify the health care provider immediately.
13. Assess the vital signs and intake and output record. - Correct Answers: Answer: 2 Which nursing interventions should a nurse implement when removing an indwelling urinary catheter in an adult patient? (Select all that apply.)
14. Attach a 3-mL syringe to the inflation port
15. Allow the balloon to drain into the syringe by gravity
16. Initiate a voiding record/bladder diary
17. Pull the catheter quickly
18. Clamp the catheter before removal - Correct Answers: Answer: 2, 3 What best describes measurement of postvoid residual (PVR)?
19. Bladder scan the patient immediately after voiding.
20. Catheterize the patient 30 minutes after voiding.
21. Bladder scan the patient when he or she reports a strong urge to void.
22. Catheterize the patient with a 16 Fr/10 mL catheter. - Correct Answers: Answer: 1 Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)?
23. Cleansing the urinary drainage bag 3 to 4 times daily with antiseptic solution.
24. Hanging the urinary drainage bag below the level of the bladder.

The urinalysis of Ms. Hathaway reveals a high bacteria count. Ampicillin is prescribed for her UTI. The teaching plan for the prevention of a UTI should include all of the following except:

1. Drink at least 2000 mL of fluid daily.
2. Always wipe the perineum from front to back.
3. Drink plenty of orange and grapefruit juices.
4. Explain the possible side effects of medication. - Correct Answers: Answer: 4 If obstructed, which component of the urination system would cause peristaltic waves? a. Kidney b. Ureters c. Bladder d. Urethra - Correct Answers: ANS: B Ureters drain urine from the kidneys into the bladder; if they become obstructed, peristaltic waves attempt to push the obstruction into the bladder. The kidney, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur. When reviewing laboratory results, the nurse should immediately notify the health care provider about which finding? a. Glomerular filtration rate of 20 mL/min b. Urine output of 80 mL/hr c. pH of 6. d. Protein level of 2 mg/100 mL - Correct Answers: ANS: A Normal glomerular filtration rate should be around 125 mL/min; a severe decrease in renal perfusion could indicate a life-threatening problem such as shock or dehydration. Normal urine output is 1000 to 2000 mL/day; an output of 30 mL/hr or less for 2 or more hours would be cause for concern. The normal pH of urine is between 4.6 and 8.0. Protein up to 8 mg/100 mL is acceptable; however, values in excess of this could indicate renal disease. A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention.

d. Request an order for diuretics. - Correct Answers: ANS: C The nurse first should gather all assessment data to determine the potential cause of oliguria. It could be that the patient does not have adequate intake, or it could be that the bladder sphincter is not functioning and the patient is retaining water. Increasing fluids is effective if the patient does not have adequate intake, or if dehydration occurs. Caffeine can work as a diuretic but is not helpful if an underlying pathology is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action. A patient requests the nurse's assistance to the bedside commode and becomes frustrated when unable to void in front of the nurse. The nurse understands the patient's inability to void because a. Anxiety can make it difficult for abdominal and perineal muscles to relax enough to void. b. The patient does not recognize the physiological signals that indicate a need to void. c. The patient is lonely, and calling the nurse in under false pretenses is a way to get attention. d. The patient is not drinking enough fluids to produce adequate urine output. - Correct Answers: ANS: A Attempting to void in the presence of another can cause anxiety and tension in the muscles that make voiding difficult. The nurse should give the patient privacy and adequate time if appropriate. No evidence suggests that an underlying physiological or psychological condition exists. The nurse knows that indwelling catheters are placed before a cesarean because a. The patient may void uncontrollably during the procedure. b. A full bladder can cause the mother's heart rate to drop. c. Spinal anesthetics can temporarily disable urethral sphincters. d. The patient will not interrupt the procedure by asking to go to the bathroom. - Correct Answers: ANS: C Spinal anesthetics may cause urinary retention due to the inability to sense or carry out the need to void. The patient is more likely to retain urine, rather than experience uncontrollable voiding. With spinal anesthesia, the patient will not be able to ambulate during the procedure. A full bladder has no impact on the pulse rate of the mother. The nurse knows that urinary tract infection (UTI) is the most common health care-associated infection because a. Catheterization procedures are performed more frequently than indicated. b. Escherichia coli pathogens are transmitted during surgical or catheterization procedures.

b. A urinary catheter. c. Diuretic medication. d. A renal angiogram. - Correct Answers: b. A urinary catheter. A urinary catheter would relieve urinary retention. Reducing fluids would reduce the amount of urine produced but would not alleviate the urine retention. Diuretic medication would increase urine production and may worsen the discomfort caused by urine retention. A renal angiogram is an inappropriate diagnostic test for urinary retention Upon palpation, the nurse notices that the bladder is firm and distended; the patient expresses an urge to urinate. The nurse should follow up by asking a. "When was the last time you voided?" b. "Do you lose urine when you cough or sneeze?" c. "Have you noticed any change in your urination patterns?" d. "Do you have a fever or chills?" - Correct Answers: ANS: A To obtain an accurate assessment, the nurse should first determine the source of the discomfort. Urinary retention causes the bladder to be firm and distended. Further assessment to determine the pathology of the condition can be performed later. Questions concerning fever and chills, changing urination patterns, and losing urine during coughing or sneezing focus on specific pathological conditions.

11. Which of the following is the primary function of the kidney? a. Metabolizing and excreting medications b. Maintaining fluid and electrolyte balance c. Storing and excreting urine d. Filtering blood cells and proteins - Correct Answers: ANS: B The main purpose of the kidney is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the byproducts of medication metabolism. The bladder stores and excretes urine. The kidneys help to maintain red blood cell volume by producing erythropoietin. While receiving a shift report on a patient, the nurse is informed that the patient has urinary incontinence. Upon assessment, the nurse would expect to find

a. An indwelling Foley catheter. b. Reddened irritated skin on the buttocks. c. Tiny blood clots in the patient's urine. d. Foul-smelling discharge indicative of a UTI. - Correct Answers: ANS: B Urinary incontinence is uncontrolled urinary elimination; if the urine has prolonged contact with the skin, skin breakdown can occur. An indwelling Foley catheter is a solution for urine retention. Blood clots and foul-smelling discharge are often signs of infection. Which nursing diagnosis related to alternations in urinary function in an older adult should be a nurse's first priority? a. Self-care deficit related to decreased mobility b. Risk of infection c. Anxiety related to urinary frequency d. Impaired self-esteem related to lack of independence - Correct Answers: ANS: B Older adults often experience poor muscle tone, which leads to an inability of the bladder to fully empty. Residual urine greatly increases the risk of infection. Following Maslow's hierarchy of needs, physical health risks should be addressed before emotional/cognitive risks such as anxiety and self- esteem. Decreased mobility can lead to self-care deficit; the nurse's priority concern for this diagnosis would be infection, because the elderly person must rely on others for basic hygiene. A patient asks about treatment for urge urinary incontinence. The nurse's best response is to advise the patient to a. Perform pelvic floor exercises. b. Drink cranberry juice. c. Avoid voiding frequently. d. Wear an adult diaper. - Correct Answers: ANS: A Poor muscle tone leads to an inability to control urine flow. The nurse should recommend pelvic muscle strengthening exercises such as Kegel exercises; this solution best addresses the patient's problem. Drinking cranberry juice is a preventative measure for urinary tract infection. The nurse should not encourage the patient to reduce voiding; residual urine in the bladder increases the risk of infection. Wearing an adult diaper could be considered if attempts to correct the root of the problem fail.