Chapter 43: Urinary Elimination

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Chapter 43: Urinary Elimination

Potter et al: Canadian Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

• If obstructed, which component of the urination system would cause peristaltic waves?
• Kidneys.
• Ureters.
• Bladder.
• Urethra.

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 kidneys, bladder, and urethra do not produce peristaltic waves. Obstruction of both bladder and urethra typically does not occur.

DIF: Remember REF: 1167 OBJ: Describe the process of urination.TOP: Evaluate MSC: NCLEX: Physiological Integrity

• When reviewing laboratory results, the nurse should immediately notify the health care

provider about which finding?

• Glomerular filtration rate of 20 mL/min
• Urine output of 80 mL/hr
• pH of 6.4
• Protein level of 2 mg/100 mL

ANS: A

Normal glomerular filtration rate should be approximately 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 levels up to 8 mg/100 mL are acceptable; however, values in excess of this could indicate renal disease.

DIF: Apply REF: 1172 OBJ: Describe the nursing implications of common diagnostic tests of the urinary system.TOP: Implementation MSC: NCLEX: Physiological Integrity

• A patient is experiencing oliguria. Which action should the nurse perform first?
• Increase the patient’s intravenous fluid rate.
• Encourage the patient to drink caffeinated beverages.
• Assess for bladder distension.
• Request an order for diuretics.

ANS: C

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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 pathological process is present. An order for diuretics can be obtained if the patient was retaining water, but this should not be the first action.

DIF: Analyze REF: 1174| 1175 OBJ: Describe characteristics of normal and abnormal urine. TOP: Assessment MSC: NCLEX: Physiological Integrity

• 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 that the patient is unable to void for which reason?

• Anxiety can make it difficult for abdominal and perineal muscles to relax enough

to void.

• The patient does not recognize the physiological signals that indicate a need to

void.

• The patient is lonely, and calling the nurse in under false pretenses is a way to get

attention.

• The patient is not drinking enough fluids to produce adequate urine output.

ANS: A

Attempting to void in the presence of another person can cause anxiety and tension in the muscles, which makes 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.

DIF: Understand REF: 1168 (Box 43-1)

OBJ: Identify factors that commonly influence urinary elimination.

TOP: Implementation MSC: NCLEX: Psychosocial Integrity

• The nurse knows that urinary tract infection (UTI) is the most common health care–associated

infection for which of the following reasons?

• Catheterization procedures are performed more frequently than indicated.
• Escherichia coli pathogens are transmitted during surgical or catheterization

procedures.

• Perineal care is often neglected by nursing staff.
• Bedpans and urinals are not stored properly and transmit infection.

ANS: B

• coli is the leading pathogenic cause of UTIs; this pathogen enters during invasive

procedures. Sterile technique is imperative to prevent the spread of infection. Frequent catheterizations can place a patient at high risk for UTI; however, infection is caused by bacteria, not by the procedure itself. Perineal care is important, and buildup of bacteria can lead to infection, but this is not the primary cause. Bedpans and urinals may become bacteria ridden and should be cleaned frequently; however, bedpans and urinals are not inserted into the urinary tract, and so they are unlikely to be the primary cause of UTI.

DIF: Understand REF: 1169

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OBJ: Compare common alterations in urinary elimination. TOP: Implementation MSC: NCLEX: Physiological Integrity

• An 86-year-old patient tells the nurse that she is experiencing uncontrollable leakage of urine.

Which nursing diagnosis should the nurse include in the patient’s plan of care?

• Urinary retention.
• Hesitancy.
• Urgency.
• Urinary incontinence.

ANS: D

Age-related changes such as loss of pelvic muscle tone can cause involuntary loss of urine, known as urinary incontinence. Urinary retention is the inability to empty the bladder.Hesitancy occurs as difficulty initiating urination. Urgency is the feeling of needing to void immediately.

DIF: Apply REF: 1169 OBJ: Identify nursing Diagnosis appropriate for patients with alterations in urinary elimination.TOP: Planning MSC: NCLEX: Physiological Integrity

• A patient has fallen several times in the past week when attempting to get to the bathroom.

The patient informs the nurse that he gets up three or four times a night to urinate. Which recommendation by the nurse is most appropriate in correcting this urinary problem?

• Clear the path to the bathroom of all obstacles before bed.
• Leave the bathroom light on to illuminate a pathway.
• Limit fluid and caffeine intake before bed.
• Practise Kegel exercises to strengthen bladder muscles.

ANS: C

Reducing fluids, especially caffeine and alcohol, before bedtime can reduce nocturia. Clearing a path to the restroom or illuminating the path, or shortening the distance to the restroom, may reduce falls but will not correct the urination problem. Kegel exercises are useful if a patient is experiencing incontinence.

DIF: Apply REF: 1169 OBJ: Discuss nursing measures to promote normal micturition and to reduce episodes of

incontinence. TOP: Implementation

MSC: NCLEX: Physiological Integrity

• When caring for a patient with urinary retention, the nurse would anticipate an order for which

of the following?

• Limited fluid intake.
• A urinary catheter.
• Diuretic medication.
• Renal angiography.

ANS: B

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. Renal angiography is an inappropriate diagnostic test for urinary retention.

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Canadian Fundamentals of Nursing 6th Edition Potter Test Bank

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DIF: Apply REF: 1169 (Table 43-1) OBJ: Discuss nursing measures to promote normal micturition and to reduce episodes of

incontinence. TOP: Implementation

MSC: NCLEX: Physiological Integrity

• 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 which question?

• “When was the last time you voided?”
• “Do you lose urine when you cough or sneeze?”
• “Have you noticed any change in your urination patterns?”
• “Do you have a fever or chills?”

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 pathological process 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.

DIF: Apply REF: 1171| 1181

OBJ: Obtain a nursing history for a patient with urinary elimination problems.

TOP: Implementation MSC: NCLEX: Physiological Integrity

• Which of the following is the primary function of the kidneys?
• Metabolizing and excreting medications.
• Maintaining fluid and electrolyte balance.
• Storing and excreting urine.
• Filtering blood cells and proteins.

ANS: B

The main purpose of the kidneys is to maintain fluid and electrolyte balance by filtering waste products and regulating pressures. The kidneys filter the by-products of medication metabolism. The bladder stores and excretes urine. The kidneys help maintain red blood cell volume by producing erythropoietin.

DIF: Understand REF: 1166 OBJ: Describe the process of urination.TOP: Assessment MSC: NCLEX: Physiological Integrity

• While receiving a shift report on a patient, the nurse is informed that the patient has urinary

incontinence. Upon assessment, what would the nurse expect to find?

• An in-dwelling Foley catheter.
• Reddened irritated skin on the buttocks.
• Tiny blood clots in the patient’s urine.
• Foul-smelling discharge indicative of a UTI.

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.

DIF: Apply REF: 1169| 1171 OBJ: Compare common alterations in urinary elimination. TOP: Assessment

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