Urinary Patterns Case Study
Prior to his stroke, Clyde often awakened 5 or 6 times during the night to void but was able to control the urge long enough to make it to the bathroom.
1. How should the nurse describe the pre-stroke urinary pattern?
This refers to frequently voiding at night. The incidence of nocturia increases greatly in the older adult.
Incontinence is the involuntary loss of urine. In the case of this client, it may be the result of neurologic impairment secondary to the stroke.
3. Which instruction should the nurse provide the unlicensed assistive personnel (UAP) who will be helping care for Clyde?
A. Restrict oral fluids to 1,000 ml daily in evenly divided amounts.
B. Offer warm coffee, cocoa, or tea every 2 hours while awake.
C. Limit client socialization until voiding patterns are established.
D. Remind the client to void every 2 hours while awake.
A toileting schedule is an effective means to retrain the bladder. Bladder training should start with voiding every 2 hours in the daytime and every 4 hours at night then be adapted to the individual needs.
4. When establishing Clyde’s plan of care, the nurse include which nursing diagnosis?
A. Fluid volume deficit related to voiding patterns.
B. Fluid volume excess related to altered urination.
C. Risk for uremic syndrome related to unresolved incontinence.
D. Risk for impaired skin integrity related to urinary incontinence.
The skin of the client with urinary incontinence is frequently exposed to urine, which is irritating to the skin and places the client at risk for impaired skin integrity.
5. What action should the nurse implement?
A. Commend the UAP for the good care being provided to the client.
B. Advise the UAP to avoid the use of any soap around the perineal area.
C. Instruct the UAP that the application of lotions and ointments increases the risk of skin breakdown.
D. Suggest that the UAP continue with the current actions and also massage any reddened areas.
Mild soap and warm water should be used to cleanse the skin followed by a protective ointment. These water-repellant ointments help protect the skin from the acidic effects of urine.
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6. Which technique(s) should be included when applying the condom catheter? (select all that apply.)
A. Clean and dry the penis before applying the condom catheter.
B. Secure the condom with adhesive tape to prevent dislodgment while ambulatory.
C. Ensure the condom with adhesive tape to prevent dislodgment while ambulatory.
D. Return the foreskin to its normal position after applying skin prep to the penis shaft.
E. Attach a large leg drainage bag to reduce the frequency of bag emptying while ambulatory.
Cleaning and drying the penis will help prevent skin irritation and breakdown.
D. Return the foreskin to its normal position after applying skin prep to the penis shaft.
After providing perineal care and applying the skin prep provided with the condom catheter, the nurse should return the foreskin to its normal position (if the client is uncircumcised) before smoothly rolling the condom sheath onto the penis.
7. What action should the nurse take?
A. Suggest the use of a smaller diameter catheter.
B. Recommend the use of a straight rubber catheter.
C. Advise the student to use a larger ballon.
D. Affirm that the student has the correct equipment.
A size 16 or 18 Foley catheter is the size typically inserted in adult males. The catheter diameter size increases with increasing numbers, so a size 22 is a larger size diameter than is typically necessary for the adult male.
8. Which physiologic change that commonly occurs in elderly males may affect insertion of the catheter?
A. Prostate gland enlargement.
B. Urethral stricture.
C. Diminished bladder capacity.
D. Weakened detrusor muscle.
The prostate gland often begins to enlarge after the age of 40, making urethral catheterization more difficult if the gland compresses the urethra.
9. The nurse should advise the student to take what action?
A. Reassure the client that the pain he is experiencing is only temporary.
B. Tape the catheter to the client’s abdomen to prevent further movement.
C. Remove the catheter from the urethra immediately.
D. Deflate the ballon, and insert the catheter farther.
The catheter has not been inserted far enough, and the pressure of the inflated balloon in the urethra is painful. Since the student has maintained aseptic technique, the balloon can be deflated and the catheter inserted farther. Typically, the catheter should be inserted 6 to 9 inches to ensure proper placement in the adult male.
10. In documenting the catheter insertion procedure, which statement should be included?
A. No prostate gland enlargement noted during catheter insertion.
B. 16 Foley catheter inserted with return of clear, yellow urine.
C. 5 ml balloon inflated in the urethra but client is now comfortable.
D. Indwelling catheter inserted because the client is incontinent.
This statement includes the best objective data, including the size of the catheter and the outcome of the procedure. In addition, the nurse should also document how the client tolerated the procedure and the client’s condition following completion of the procedure.
11. Which recording objectively documents the situation?
A. Client does not know what he is doing, and he has caused bleeding to occur in the urine.
B. Surgery caused client’s confusion, resulting in pulling on the catheter and hemorrhage.
C. Client is confused and pulls on the foley catheter. Urine is pinkish-red with blood clots.
D. The client was instructed not to pull on his catheter, and now there is hematuria in the tubing.
This recording is concise but complete, providing objective data that describes the current situation.
12. What assessment should the nurse complete first?
A. Palpate for bladder distention.
B. Obtain the blood pressure.
C. Measure the oxygen saturation.
D. Observe urinary drainage tubing.
The client has had no urine output in 2 hours, he has been experiencing blood clots in his urine, and he is in obvious discomfort. The nurse should first consider that the catheter tubing is obstructed and assess for kinks or pressure on the tubing that might cause the obstruction. The nurse should also not the presence of any observable blood clots, which can also obstruct the urine flow. This simple noninvasive measure could easily identify and immediately resolve the client’s discomfort.
13. The nurse anticipates that the prescription will include the use of which sterile solution to irrigate the catheter?
A. Normal saline.
B. Hydrogen peroxide.
C. Heparinized saline solution.
D. Chlorhexidine antimicrobial solution.
An isotonic saline is a sterile normal solution that can be used for internal organ irrigations such as the bladder or stomach.
14. What action should the nurse take?
A. Encourage the student to continue, maintaing aseptic technique.
B. Instruct the student to instill 30 ml of air, followed by 30 ml of solution.
C. Advise the student to leave the distal clamp in place for 30 minutes.
D. Remind the student to empty the drainage bag before instilling the solution.
The student is performing the procedure correctly. Irrigation may also be performed by opening the connection between the catheter and the drainage tubing, but opening that connection increases the risk of contamination.
15.What output should be recorded? (Numerical value only, if rounding, round to whole number.)
The student instilled 20 ml more than was withdrawn, so that amount must be subtracted from the volume emptied from the drainage bag. (200 mL-20 mL=180mL). The nurse may instill the irrigant without withdrawing any fluid. In that circumstance the entire amount of the irrigant must be subtracted from the amount of fluid emptied from the drainage bag to obtain an accurate measurement of the client’s output.
16. The nurse considers the use of wrist restraints, based on which rationale?
A. The client is confused.
B. The client just had surgery.
C. The client is at risk for self-injury.
D. There is no family member present to stay with the client.
Risk of self-injury is a reasonable rationale for the use of physical restraints. However, all other safety measure should be attempted before physically restraining a client.
17. Which assessment is most important for the nurse to perform at each of these times?
A. Skin integrity is most important for the nurse to perform at each of these times.
B. Auscultation of bilateral breath sounds and heart sounds.
C. Vital signs and oxygen saturation via pulse oximetry.
D. The presence and integrity of all invasive tubes.
Wrist restraints can impede circulation, causing tissue damage under the restraint and distal to the restraint. Skin integrity and assessment of distal circulation (including pulse volume, color, warmth, and sensation) must be assessed every 30 minutes, and the restraints removed at least every 2 hours to allow for ROM.
A. Assess the client’s skin turgor.
B. Continue the catheter irrigations.
C. Obtain a sterile urine specimen.
D. Palpate the bladder for distention.
Clyde’s confusion decreases, and 12 hours later the nurse is able to remove the wrist restraints. By the third postoperative day, no further hematuria or blood clots are observed in Clyde’s urine. However, the nurse does observe that the urine has developed a cloudy appearance.
Urine develops a cloudy appearance when a urinary tract infection has developed. A sterile specimen is needed to detect and ID microorganisms.
Urinalysis results are:
Specific gravity 1.015
Based on the urinalysis results, the healthcare provider prescribes a broad spectrum antibiotic.
19. What additional nursing intervention will the nurse implement?
A. Encourage the intake of high-protein foods.
B. Offer additional high-carbohydrate snacks.
C. Reduce the client’s water intake.
D. Provide a glass of cranberry juice daily.
The pH of the client’s urine is elevated, indicating alkaline urine. Cranberry juice is believed to increase the acidity of urine, providing a less desirable environment for bacterial growth.
A. Serum creatinine and BUN are both elevated above normal.
B. Urine culture shows resistance to the prescribed antibiotic.
C. Partial thromboplastin time (PTT) is excessively prolonged.
D. CBC shows low hemoglobin and hematocrit levels.
If the microorganisms causing the urinary tract infection are resistant to the prescribed antibiotic, the antibiotic is ineffective, and the client is at risk for sepsis, or generalized infection.
21. Since Clyde’s creatinine level is elevated, the nurse is concerned about which problem in administering the medication?
A. Drug toxicity due to reduced drug excretion.
B. Decreased effectiveness due to poor absorption.
C. Altered first-pass effect due to reduced liver function.
D. Increased free drug molecules due to low albumin levels.
An elevated creatinine level reflects a problem with the kidneys. If the kidneys are unable to excrete drug molecules efficiently, the drug will remain in the body for a prolonged period of time, which may result in drug toxicity.
22. The nurse recognized that the frequency of drug administration is based on which characteristic of the medication?
B. Protein binding.
C. Therapeutic index.
Half-life describes the length of time required to reduce the drug level to one half of its initial value. Drugs with shorter half-lives will have to be given more frequently than those with longer half-lives.
23. The nurse instructed the UAP to report if Clyde has not voided within what time period?
A. 2 hours
B. 4 hours
C. 8 hours
D. 12 hours
Generally, if the client has not voided within 6 to 8 hours of catheter removal, further action should be taken. That may include reinserting a catheter.
A. Apply firm pressure to the bladder for 2-3 minutes.
B. Turn on the tap so water is running when the client attempts to void.
C. Place the client’s hands in a basin of ice cold water.
D. Place the client in a left lateral Sim’s position.
Clyde voids 4 hours after the catheter is removed. He is discharged to the long-term care facility.
Running water often stimulates the urge to void, as does placing the client’s hands in warm water.
25. Before deciding to open the capsule and mix it with food, what will the nurse need to determine?
A. Is the capsule scored for ease of opening?
B. Was Clyde able to swallow the capsules prior to his stroke?
C. Is the medication in extended-release form?
D. Does the medication come in unit dose packaging?
An extended-release medication if formulated for gradual absorption in the body. Opening or crushing the medication will adversely affect this action.
26. Which technique will the nurse use?
A. Crush the capsule and mix with applesauce.
B. Open the capsule and mix the medication with pudding.
C. Dissolve the capsule in a glass of warm milk.
D. Open the capsule and mix in a glass of fruit juice.
Opening the capsule allows the client who receive the medication enclosed. Pudding is safe consistency for most clients with dysphagia, who typically have more difficulty swallowing liquids than semi-soft foods.
27. What is the best initial response by the nurse to this behavior?
A. Leave Clyde alone until his crying subsides.
B. Assign a UAP to sit with Clyde.
C. Acknowledge to Clyde the distress that he is experiencing.
D. Provide a distraction, such as turning on the television.
Acknowledgement of a client’s distress is therapeutic and caring response. This should be the first action implemented by the nurse.
28. Which aspect of the situation requires the nurse’s most immediate intervention?
A. The room temperature seems excessively warm.
B. A soap opera is playing loudly on the TV.
C. A second UAP is watching the TV rather than helping.
D. Clyde’s room door is open to the hallway.
This is disrespectful, demeaning, and an invasion of the client’s privacy. It should be corrected immediately.
The nurse closes the door, reassures Clyde, and tells the UAPs that she would like to talk to both of them after Clyde’s care is completed.