Yoost Ch.

40 Bowl Elimination
The nurse is caring for a patient who periodically has small streaks of fresh red blood in
the stool. The patient denies abdominal
pain or loss of appetite. The nurse identifies what to be the most likely cause of this
patient’s bleeding?
a. Hemorrhoids
b. Bleeding gastric ulcer
c. Colon polyps
d. Perforated colon
The nurse is caring for a patient who periodically has small streaks of fresh red blood in
the stool. The patient denies abdominal
pain or loss of appetite. The nurse identifies what to be the most likely cause of this
patient’s bleeding?
a. Hemorrhoids
b. Bleeding gastric ulcer
c. Colon polyps
d. Perforated colon
1. The nurse is caring for a patient who periodically has small streaks of fresh red blood
in the stool. The patient denies abdominal pain or loss of appetite. The nurse
identifies what to be the most likely cause of this patient’s bleeding?
a. Hemorrhoids
b. Bleeding gastric ulcer
c. Colon polyps
d. Perforated colon

Bleeding hemorrhoids can lead to small streaks of fresh red blood in the stool. Bleeding
gastric ulcer would lead to black, tarry stools as the blood is digested. Colon polyps do not
cause bleeding.

The nurse is caring for a patient who has diarrhea and identifies which priority nursing
diagnosis for this patient?
a. Lack of knowledge related to prescribed diet modifications.
b. Impaired nutritional intake related to poor appetite.
c. Diarrhea related to excessive loss of fluid through stool.
d. Anxiety related to incontinence with loose stools and need for clothing change.
The nurse is caring for a patient who has diarrhea and identifies which priority nursing
diagnosis for this patient?
a. Lack of knowledge related to prescribed diet modifications.
b. Impaired nutritional intake related to poor appetite.
c. Diarrhea related to excessive loss of fluid through stool.
d. Anxiety related to incontinence with loose stools and need for clothing change.
2. The nurse is caring for a patient who has diarrhea and identifies which priority
nursing diagnosis for this patient?
a. Lack of knowledge related to prescribed diet modifications.
b. Impaired nutritional intake related to poor appetite.
c. Diarrhea related to excessive loss of fluid through stool.
d. Anxiety related to incontinence with loose stools and need for clothing
change.
Dehydration is the priority nursing problem for this patient, so diarrhea is the most
important nursing diagnosis. Impaired nutritional intake, lack of knowledge, and anxiety can
be addressed once fluid balance is restored.

3. The nurse is caring for a patient who is prescribed diphenoxylate-atropine (Lomotil).

Which assessment finding by the nurse indicates a need to contact the prescriber
and question the order?
a. The patient has skin breakdown from loose stools.
b. The patient is constipated with last BM 3 days ago.
c. The patient is on a low-fiber, gluten-free diet.
d. The patient has painful bleeding hemorrhoids.

Diphenoxylate-atropine is an antidiarrheal medication. It should not be given to patients who

are constipated until the patient is checked for impaction. The other assessment findings are
not contraindications.

4. The nurse is caring for an immobile patient who has abdominal pain and frequent
small, liquid stools. The patient vomited his breakfast and is still nauseated. Which
action by the nurse is the highest priority?
a. Provide oral care after each episode of emesis.
b. Apply a skin barrier to the patient’s perineal area.
c. Check the patient for a fecal impaction.
d. Administer antiemetic medication with a sip of water.

The patient who has abdominal pain and frequent small liquid stools should be checked for
fecal impaction, especially since the patient is vomiting. Immobility is a risk factor for the
development of fecal impaction. The other actions can be performed once fecal impaction is
ruled out.

5. The nurse is caring for a patient who is recovering from bowel surgery. Which
assessment finding best indicates that the bowel is starting to resume function, and
the patient will be able to resume oral intake soon?
a. The patient has bowel sounds  4 quadrants and is passing gas.
b. The patient has no nausea, and abdominal pain is minimal.
c. The patient feels hungry for chicken soup and hot tea.
d. The patient’s nasogastric tube was discontinued the previous day.

The presence of bowel sounds, and passage of flatus indicate that the patient’s bowels are
starting to resume function, and the patient will be able to resume oral intake soon. Hunger,
discontinuation of the NG tube, or absence of nausea are not definite indicators of readiness
to resume oral feedings.

6. The nurse is caring for a patient who has an ileostomy. Which nursing diagnosis has
the highest priority for the patient?
a. Impaired skin integrity r/t localized skin irritation from liquid stool.
 b. Social isolation r/t potential leakage of stool from ostomy appliance.
c. Lack of knowledge r/t care and maintenance of ostomy appliance.
d. Disturbed body image r/t presence of stoma and altered elimination.

The highest priority nursing diagnosis for this patient is impaired skin integrity because
stools from an ileostomy are frequent and liquid and cannot be regulated. Drainage contains
digestive enzymes, which can be damaging to the skin; therefore, patients with ileostomies
wear an appliance continuously and take special precautions to prevent skin breakdown. In
addition, ostomy appliances do not adhere well to open wounds, increasing the risk for
continuing skin break down. The other nursing diagnoses are appropriate for this patient but
are not the highest priority.

7. The nurse is caring for a patient who is taking narcotic pain medication after surgery.
Which breakfast choices will help prevent constipation and promote return to regular
bowel function?
a. Raisin bran with skim milk, fresh fruit, and wheat toast.
b. Pancakes with maple syrup, bacon, and coffee with cream.
c. Omelet with cheddar cheese, green pepper, and onions.
d. Bagel with cream cheese, and strawberry nonfat yogurt.

The postoperative patient taking narcotic pain medications is at risk for developing
constipation. A high-fiber diet with plenty of liquids will help prevent this from occurring.
Raisin bran, fruit, and wheat bread are all good sources of fiber.

8. The nurse is caring for a patient who has not had a bowel movement for 2 days.
Which is the priority nursing intervention for this patient?
a. Obtain an order to administer a soap suds cleansing enema.
b. Teach the patient how to use the Valsalva maneuver.
c. Discontinue medications that can cause constipation.
d. Assess the patient’s usual pattern of bowel movements.

Frequency and amount of defecation will vary and differs from person to person, ranging
from two or three times per week to several times per day. The nurse should assess the
patient’s usual pattern of bowel movements to determine if it is normal for the patient to
have a bowel movement every 2 to 3 days. Patients should be taught not to use the Valsalva
maneuver because it can lead to bradycardia or death. Medications are not independently
discontinued by the nurse, and this would require a conversation with the provider.

9. The nurse is caring for a patient who will be undergoing upper GI series testing the
next day. Which instruction will the nurse provide to the patient about the upcoming
exam?
a. “The back of your throat will be sprayed with numbing medicine.”
b. “You will need to have a clear liquid diet and take a laxative tonight.”
c. “You will be given a milky liquid to drink shortly before the test starts.”
d. “You should not take your dose of warfarin (Coumadin) tonight.”
The patient is given a milky barium liquid to drink as part of the upper GI series, so the
patient should be informed of this. The back of the throat is numbed for upper GI endoscopy,
not an upper GI series. Warfarin is not contraindicated prior to an upper GI series, and no
bowel prep is required.

10. The nurse is caring for a patient who will undergo colonoscopy testing. Which
intervention will the nurse include in the patient’s plan of care for the day before the
test?
a. Provide the patient with zinc oxide skin barrier cream for the perineal area.
b. Obtain an order for a gentle laxative to be given once the test is completed.
c. Carefully assess the patient’s ability to swallow liquids through a straw.
d. Check the patient for allergies to shellfish and iodine-based contrast dyes.

Complete bowel evacuation is required prior to colonoscopy so that the physician can
visualize the interior of the large intestine. The patient will have multiple soft-liquid bowel
movements as part of the bowel prep for the test, so skin barrier cream will be helpful to
prevent perineal irritation. Laxatives will not be needed after the colonoscopy, and no
contrast dyes are used.

11. The nurse is caring for a patient who is to have testing for fecal occult blood. What
step will the nurse perform during this testing?
a. Keep the patient on a clear liquid diet for 72 hours.
b. Put the sample container on ice and send to the lab immediately after
collection.
c. Inform the patient that several stool samples will be needed.
d. Use a sterile container when collecting the stool samples.

Three stool samples are required for fecal occult testing to avoid missing blood that appears
intermittently. A sterile container is not required, and the patient does not need to be on a
clear liquid diet for the test. Stool samples do not need to be put on ice after collection.

12. The nurse is caring for a patient who is to have a cleansing enema. Which
assessment finding by the nurse indicates a need to contact the prescriber and
question the order?

a. The patient is recovering from a traumatic brain injury.

b. The patient has not had a bowel movement for 3 days.
c. The patient is to have a lower GI series the following morning.
d. The patient had an upper GI series performed the previous day.

Patients with a traumatic brain injury often have increased intracranial pressure, which can
be worsened with enema administration, thus putting the patient at risk for additional
neurologic damage. The provider should be contacted, and the order should be questioned.
Constipation, preparation for a lower GI series, and removal of barium from the colon after
upper GI series are all indications for a cleansing enema.

13. The nurse is caring for a postoperative patient who underwent bowel resection
surgery that morning. The nurse assesses the patient’s abdomen and notes that
there are hypoactive bowel sounds. The patient is resting quietly without nausea or
vomiting. What is the appropriate action of the nurse?
a. Keep the patient NPO and document the findings in the chart.
b. Administer a laxative suppository to stimulate peristalsis.
c. Insert a Salem sump nasogastric tube to low continuous suction.
d. Notify the surgeon and prepare the patient to return to surgery.

The presence of hypoactive bowel sounds is an expected finding for the first hours after
abdominal surgery. The patient should be kept NPO to prevent nausea and vomiting. A
laxative should not be administered. A nasogastric tube is not needed unless the patient
starts vomiting or a paralytic ileus develops.

14. The nurse is caring for a patient who is constipated and has not had a bowel
movement for 3 days. The nurse performs a rectal examination and finds hard dry
stool in the rectum. What is the best option to help the patient have a bowel
movement?
a. Glass of warmed prune juice
b. Loperamide (Imodium)
c. Oral fiber supplement
d. An oil retention enema

The patient with hard, dry stool in the rectum will benefit from an oil retention enema
because it will soften the stool and make it easier to pass. Imodium is an antidiarrheal that
will worsen the constipation. An oral fiber supplement and prune juice should be given after
the patient has a bowel movement to prevent constipation from recurring.

15. The nurse is caring for a patient who has just completed 2 weeks of IV antibiotics for
a severe infection. The patient now has frequent loose watery stools and a low-grade
temperature. What is the most likely cause of the patient’s new symptoms?
a. Clostridium difficile infection
b. Paralytic ileus
c. Fecal impaction
d. Salmonella food poisoning

Diarrhea, abdominal pain, and low-grade temperature after completing IV antibiotics are
often caused by C. difficile infection.
 16. The nurse is caring for a patient who had a colonoscopy earlier that day. The patient
states that he still feels very bloated after the procedure. What is the best action of
the nurse?
a. Assist the patient to ambulate in the hall.
b. Insert a rectal tube to remove retained flatus.
c. Administer an enema to stimulate peristalsis.
d. Encourage oral intake of fluids and high-fiber foods.

Ambulation is a good way to promote peristalsis and relieve bloating. An enema should not
be used after colonoscopy. A rectal tube is not needed. Eating high-fiber foods soon after
colonoscopy may increase gas and bloating.

17. The nurse is caring for a patient with a history of dementia who is incontinent of stool
because of the inability to communicate the need to defecate. What is the priority
action of the nurse?
a. Administer a daily laxative and take the patient to the toilet afterward.
b. Digitally remove stool from the patient’s rectum every other day.
c. Insert a rectal tube to facilitate drainage of soft or liquid stool.
d. Begin a prompted toileting program to facilitate bowel continence.

Patients who cannot communicate the need to use the toilet often benefit from a prompted
toileting program in which the patient is brought to the toilet at the same times each day to
promote urinary and bowel continence. A rectal tube should not be used. Digital removal of
the impaction should be avoided whenever possible. Laxatives should be used only when
necessary because continued use will lead to dependence.

18. The nurse is caring for a patient who is recovering after hip surgery. The patient
requires assistance to use the bathroom because no weight bearing is allowed on the
right leg. Which goal is most important for the nurse to include for the diagnosis
impaired self-toileting?
a. The patient will demonstrate safe transfer technique between wheelchair and
toilet.
b. The call light will be answered promptly when the patient needs to use the
toilet.
c. Toileting will be scheduled in the morning when the patient needs to defecate.
d. Toilet paper and handwashing items will be kept within easy reach of the
patient.

The highest priority goal for this patient is the demonstration of safe transfer technique
between the chair and the toilet. The other statements are interventions performed by staff
rather than goals that will be accomplished by the patient.

19. The nurse is caring for a patient who is recovering from diarrhea. The nurse teaches
the patient about dietary recommendations as the digestive system recovers. Which
menu selection by the patient indicates that additional teaching is needed?
 a. Applesauce
b. Orange popsicle
c. White toast
d. Coffee with cream

The patient with diarrhea benefits from bland, small meals, which may be more easily
tolerated. Milk products, spices, food that irritates or stimulates the GI tract, gas-producing
foods, and caffeine are avoided. Caffeine is also a diuretic, which can lead to continued
dehydration.

20. The nurse is caring for a patient who has had a severe stroke and requires assistance
to use the toilet. Which goal is the highest priority for this patient?
a. The patient will remain continent with no perineal skin breakdown.
b. The patient will state satisfaction with use of gait belt for toilet transfers.
c. The patient will regain ability to pull up clothing after using the toilet.
d. The patient will have privacy once properly positioned on the toilet.

The highest priority goal for this patient is continence with no perineal skin breakdown to
maintain skin integrity and self-esteem. Patient statements of satisfaction and the ability to
pull up clothing are important but not the priority over preventing skin breakdown. Privacy is
an intervention to be performed by the staff rather than a goal for the patient.

21. A student nurse is working with a preceptor to administer an enema to the patient.
Which action by the student prompts intervention and redirection by the preceptor?
a. Water-soluble lubricant is applied to the end of the enema tubing.
b. The enema tubing is primed with solution that has been warmed.
c. The patient is positioned comfortably in the modified left lateral recumbent
position.
d. The patient’s bedpan is put at the bedside in preparation for use.

The patient should be placed in the modified left lateral recumbent position prior to enema
administration so that the enema fluid will readily flow through the colon by gravity. The
other actions demonstrate correct enema administration steps.

22. The nurse is caring for a postoperative patient who had a colostomy placed 2 days
ago. The appliance needs to be changed for the first time. Which ostomy care actions
can the nurse delegate to the nursing assistant? (Select all that apply.)
a. Gently cleaning the stoma with warm water and a washcloth
b. Assessing the stoma and incision for signs of infection or ischemia
c. Obtaining needed supplies from the clean utility room
d. Teaching the patient how to care for the ostomy after discharge
e. Determining which type of ostomy appliance to use
f. Application of skin protectant to the area surrounding the stoma
The nursing assistant can gently clean the stoma with warm water and a washcloth, obtain
needed supplies, and apply skin protectant. The nurse is responsible for assessment,
teaching, and determining which ostomy appliance to use.

23. The nurse is caring for a patient who will be having a colonoscopy the following
morning. Which items must be removed from the patient’s dinner tray since they are
not allowed prior to the test? (Select all that apply.)
a. Cherry-flavored gelatin
b. Cream of chicken soup
c. Glass of apple juice
d. Coffee with cream and sugar
e. Lemon-flavored Italian ice
f. Can of ginger ale

Patients who will undergo colonoscopy testing should have a clear liquid diet the day before
the exam, so cream of chicken soup and coffee creamer should not be consumed. Foods
with red food or purple dye should also be avoided prior to colonoscopy.

Chapter 41: Urinary Elimination

1. The nurse is caring for a patient who is recovering from septic shock. While in the
ICU, the patient developed renal failure. The nurse recognizes which type of renal
failure the patient most likely developed?
a. Prerenal
b. Renal
c. Postrenal
d. Mixed

Prerenal failure occurs as a result of reduction in blood flow to the kidneys, which would
occur with septic shock. Causes of prerenal failure include dehydration, vascular collapse,
and low cardiac output. Structural issues with the kidneys, from primary glomerular diseases
or vascular lesions, result in renal failure. Postrenal failure is related to a mechanical or
functional obstruction of the flow of urine.

2. The nurse is caring for a patient with a neurological condition that causes
constant severe thirst, drinking fluids continuously, and voiding 3 to 4 L of clear
yellow urine daily. Which term will the nurse use in the record to describe this
patient’s urinary output?
a. Anuria
b. Oliguria
c. Polyuria
d. Enuresis

Urinary output greater than 2500 mL/day is polyuria. Insufficient urine output is oliguria,
whereas absence of urine is anuria. Enuresis is commonly known as “bedwetting” at night.
 3. The nurse is caring for a patient who is experiencing stress incontinence. The
nurse identifies which goal to be the most important for this patient?
a. The patient will carefully complete a voiding diary for the duration of 2 weeks.
b. The patient will not experience involuntary urination during coughing or
sneezing.
c. The patient will be able to recognize and effectively manage perineal
dermatitis.
d. The patient will demonstrate how to appropriately use urinary incontinence
products.

The patient with stress incontinence experiences loss of urine when coughing, sneezing,
laughing, or exercising. The highest priority goal for this patient is to not experience
incontinence at all and remain continent through all daily activities. If the patient remains
continent, perineal dermatitis will not be a problem and urinary incontinence products will
not be needed.

4. The nurse is caring for a postoperative patient whose urinary catheter was
removed 8 hours previously. The patient has not been able to void since the
catheter was removed and now reports suprapubic pain. What is the priority
action of the nurse?
a. Encourage oral fluid intake and administer a diuretic.
b. Obtain a urine sample to test for culture and sensitivity.
c. Calculate the patient’s daily intake and output.
d. Obtain an order to straight-catheterize the patient.

If the patient has not urinated during the 6 to 8 hours after removal of a urinary catheter:
assess for urinary retention via bladder scan, notify the primary care provider (PCP), and
intermittent catheterization with a straight catheter or reinsertion of an indwelling catheter
may be necessary. Since the patient has not voided for 6 to 8 hours after urinary catheter
removal and is complaining of suprapubic pain has acute urinary retention, the physician
should be notified to obtain an order for straight catheterization to drain the bladder. A urine
sample for culture and sensitivity is not ordered. Encouraging fluid intake and administering
a diuretic will increase the amount of urine in the bladder and make the patient even more
uncomfortable.

5. The nurse is caring for a patient who recently underwent ileal conduit surgery.
Which nursing diagnosis is the highest priority for this patient?
a. Impaired sexual function related to changed body structure
b. Social isolation related to potential for accidental leakage of urine
c. Lack of knowledge related to care and maintenance of ostomy appliance
d. Disturbed body image related to presence of stoma and appliance

The patient with a new ileal conduit needs to learn how to care for the urinary stoma and
appliance prior to discharge from the hospital. If the appliance is not used and applied
correctly, the patient may experience urinary leakage and significant skin breakdown from
exposure to urine. The other diagnoses are less important than the patient’s lack of
knowledge about ostomy care.

6. The nurse is caring for a patient who reports an urgent need to urinate but is
unable to pass more than a few drops of urine in the toilet. Which is the priority
assessment to be performed by the nurse?
a. Bladder scan to determine the amount of urine in the bladder.
b. Auscultation to assess circulation through the right and left renal arteries.
c. Bimanual palpation to assess for possible enlargement of the kidneys.
d. Calculate the patient’s intake and output to check for fluid volume deficit.

The patient with suspected urinary retention should have a bladder scan performed to
determine the amount of urine in the bladder. If a significant amount of urine is found in the
bladder, the provider may be notified to obtain an order for straight catheterization.

7. The nurse is caring for a seriously ill patient whose laboratory results show a
serum creatinine level of 3.5 mg/dL and a serum BUN of 35 mg/dL. Which
conclusion can the nurse draw from these test results?
a. The patient is severely dehydrated.
b. The patient’s kidneys have been damaged.
c. The patient has a urinary tract infection.
d. The patient has developed a renal calculus.

Elevated BUN and creatinine are found in laboratory test results when the kidneys have
been damaged and are unable to sufficiently clear metabolic wastes from the bloodstream.
A dehydrated patient may have an elevated BUN, but the serum creatinine should be
normal. Urinary tract infection and kidney stone (renal calculus) would not cause elevated
BUN and creatinine levels.

8. The nurse is caring for a patient who has developed kidney failure. Which test
finding leads the nurse to contact the nephrologist and arrange for emergency
hemodialysis?
a. Potassium level 6.8 mmol/L
b. Serum creatinine level of 2.8 mg/dL
c. Large amounts of protein in the urine
d. 1500 mL of retained urine in the bladder

Patients in renal failure often require dialysis to reduce serum potassium levels to less than
5.5 mmol/L. Critically high serum potassium levels can lead to lethal arrhythmias and must
be corrected promptly. Patients with advanced renal failure may require emergency
hemodialysis if the potassium level does not lower with other methods (insulin and 50%
dextrose, kayexalate). An elevated creatinine is consistent with kidney dysfunction. Large
amounts of protein in the urine occur in some diseases. 1500 mL of retained urine requires
straight catheterization.
 9. The nurse is caring for a patient who will undergo ultrasound testing of the
bladder and kidneys the next morning. Which instruction will the nurse provide to
the patient about the test?
a. “A small IV will be inserted into your arm to inject the contrast dye.”
b. “You will need to drink lots of water but not use the toilet.”
c. “You should not have anything to eat or drink after midnight.”
d. “You will receive a cleansing enema before you have the test.”

No preparation is needed for kidney and bladder ultrasound other than having the patient
drink lots of fluid beforehand. The patient is instructed not to use the toilet so that the
bladder will be filled and easy to visualize. No contrast dye, enemas, or fasting is required.

10. The nurse is caring for a patient who has urinary retention resulting from benign
prostatic hyperplasia (BPH). The patient requires catheterization in order to drain
the urine from his bladder. Which action will the nurse take to facilitate this
procedure?
a. Obtain a Coudé catheter for insertion.
b. Attach a leg bag to the catheter prior to insertion.
c. Trim the pubic hair before cleaning the perineal area.
d. Wait until the bladder is full to perform catheterization.

A Coudé catheter is used when there is narrowing or constriction of the urethra, making
insertion of a regular indwelling catheter difficult. The Coudé catheter has a special tip on
the end that is designed to facilitate insertion of the catheter through the narrowed urethra
caused by BPH. Coudé catheters may need to be placed using a metal wire introducer.
Placement using an introducer typically is performed by a provider or the patient’s urologist,
to avoid damaging urethral tissue. Trimming the pubic hair will not facilitate catheterization.
Attaching a leg bag to the catheter prior to insertion is not needed because a bedside
collection bag will usually be used initially.

11. The nurse is caring for an incontinent male patient who has a deep decubitus
ulcer on his sacrum. Which intervention will best manage the patient’s urinary
incontinence and facilitate healing of the ulcer?
a. Use of disposable absorbable incontinence briefs
b. Daily application of perineal barrier cream containing zinc oxide
c. Careful perineal care and application of a condom catheter
d. Insertion of a single-lumen straight urinary catheter

Condom catheters allow for collection of urine in the incontinent patient without the
infection risks of an indwelling catheter. The condom catheter is applied to the outside of the
penis like a condom instead of being inserted into the urethra. Careful perineal care is
performed prior to application of the condom catheter and regularly thereafter. Use of
disposable briefs or perineal barrier cream will not facilitate healing of the sacral ulcer. A
single-lumen straight urinary catheter is used to drain the bladder to relieve urinary
retention or to obtain a urine sample for testing. A straight catheter is not used for
management of incontinence.

12. The nurse is caring for a patient who has urinary frequency. Which nursing
diagnosis is the highest priority for this patient?
a. Impaired urination r/t occasional incontinence
b. Anxiety r/t living alone at home with nocturia
c. Risk for infection r/t urine contact with perineal area skin
d. Risk for fall-related injury r/t hurried trips to the bathroom during the day and
night

Risk for fall-related injury is the highest priority diagnosis for this patient because rushing to
the bathroom can lead to loss of balance and serious injury. Walking to the bathroom at
night is even more dangerous because of low lighting conditions and sleepiness. The other
nursing diagnosis may be appropriate but not higher than the injury risk.

13. The nurse is caring for a patient who has just had an intravenous pyelography
(IVP) completed. Which assessment is the nurse’s highest priority after the
patient returns from the test?
a. Calculate the patient’s intake and output.
b. Monitor for discoloration of the patient’s urine.
c. Assess for possible iodine or shellfish allergies.
d. Inquire if the patient has burning or pain with urination.

The nurse must carefully monitor the patient’s intake and output after IVP testing to ensure
that the patient’s kidneys were not damaged by the contrast dye. PO fluid intake should be
encouraged to facilitate excretion of the contrast dye. Urine is not discolored from the IVP.
Burning or pain with urination should not occur after IVP testing because there is no
instrumentation of the urinary tract. Assessment of allergies must be done before the IVP is
done because iodine-based contrast is used.

14. The nurse is caring for a patient with benign prostatic hypertrophy who states
that he feels a constant urge to urinate but cannot pass more than 30 to 60 mL of
urine at a time. The nurse performs a bladder scan and finds that there are 1100
mL of urine in the patient’s bladder. What is the priority nursing diagnosis for this
patient?
a. Anxiety r/t continual urge to urinate
b. Reflex incontinence of urine r/t over-distention of the bladder
c. Impaired urination r/t obstruction of urinary bladder outlet
d. Impaired self-toileting r/t inability to pass urine into the toilet

The patient has acute urinary retention with overflow as evidenced by 1100 mL of urine in
the bladder and frequent passage of small amounts of urine. The priority nursing diagnosis
is thus impaired urination r/t obstruction of urinary bladder outlet. Urinary retention is the
cause of the patient’s discomfort and drainage of the bladder will result in relief of the
patient’s symptoms. The patient is able to get himself on and off the toilet, so toileting self-
care deficit is not a problem. Reflex incontinence of urine r/t over-distention of the bladder is
not as specific to this scenario as the nursing diagnosis of impaired urination.

15. The nurse is caring for a patient who had prostate surgery the previous day. The
patient has had significantly decreased urine output over the last shift despite
ample oral and IV fluid intake. The patient’s urine from the indwelling catheter is
cherry red with occasional small clots. What is the appropriate action of the
nurse?
a. Remove the urinary catheter and replace it with a new one.
b. Gently irrigate the catheter using room-temperature sterile irrigation solution.
c. Send a sample of the patient’s urine to the laboratory for analysis.
d. Call the provider and obtain an order for kidney and bladder ultrasound.

The patient most likely has decreased urine output caused by clot formation that is blocking
urine from draining through the catheter. The catheter should be gently irrigated using
sterile technique and room-temperature sterile irrigation solution to loosen clots and
facilitate urinary drainage. The catheter should not be removed. Ultrasound and urinalysis
are not necessary.

16. The nurse is caring for a patient with the nursing diagnosis of urge incontinence
of urine related to urinary tract infection. Which statement is appropriate for the
“as evidenced by” portion of the patient’s diagnosis?
a. Sudden leakage of urine when patient is unable to get to the toilet in time
b. Continuous urine flow from the bladder regardless of attempts to use the toilet
c. Leakage of urine from the bladder when the patient coughs, sneezes, or
laughs
d. Leakage of urine because the patient is unable to indicate need to use the
toilet

Urge incontinence involves a sudden strong urge to void, followed by rapid bladder
contraction. The affected person does not have enough time for toileting between
recognition of the urge to urinate and the onset of voiding. Continuous flow of urine is
deemed total urinary incontinence. Leakage of urine when sneezing or coughing is stress
incontinence. Functional incontinence occurs when the patient cannot indicate need to use
the toilet.

17. The nurse is caring for a patient with an indwelling urinary catheter caused by
severe prostate enlargement. Which is the priority nursing diagnosis for this
patient?
a. Risk for infection r/t indwelling urinary catheter
b. Disturbed body image r/t presence of catheter
c. Risk for contamination r/t potential leakage of urine on clothing
d. Impaired urination r/t blockage of bladder outlet
The presence of an indwelling urinary catheter puts the patient at high risk for urinary tract
infection, and this is the highest priority diagnosis for the patient. Disturbed body image is
not as important as the risk of infection. Risk for contamination is not a nursing diagnosis.
Impaired urination was corrected by placement of the urinary catheter.

18. The preceptor is watching a nursing student care for a male patient who requires
a condom catheter. Which action by the nursing student indicates that the
procedure is performed correctly?
a. Sterile gloves are donned before touching the catheter.
b. Adhesive tape is applied securely around the base of the penis.
c. Water-soluble lubricant is applied to the end of the catheter.
d. The foreskin is returned to its natural position before the catheter is applied.

The patient’s penis should be cleaned with soap and water with the foreskin retracted prior
to condom catheter application. The foreskin should then be returned to its natural position
before the catheter is applied. Adhesive tape should never be applied around the base of the
penis because circulation may be compromised. Sterile gloves and lubricant are not needed.

19. The nurse is caring for a patient with a history of type 1 diabetes. Which
assessment finding indicates to the nurse that the patient may not be compliant
with the diabetic treatment regimen?
a. The patient is always thirsty and frequently voids very large amounts of urine.
b. The patient’s urine is very concentrated with a dark amber color.
c. The patient complains of throbbing flank pain and burning with urination.
d. The patient has urinary hesitancy and difficulty initiating a stream of urine.

A noncompliant diabetic patient will have elevated blood sugars that cause thirst and
polyuria. Concentrated urine indicates dehydration. Throbbing flank pain and burning with
urination are indicative of urinary tract infection. Urinary hesitancy and difficulty initiating
urine stream are not indicative of elevated blood sugar levels.

20. The nurse is caring for a patient who is to undergo computed tomography (CT) of
the kidneys and ureters. Which assessment finding by the nurse must be
reported to the provider and radiologist before the patient has the procedure?
a. The patient is allergic to bananas and latex.
b. The patient thinks that she might be pregnant.
c. The patient has a family history of bladder cancer.
d. The patient currently has a urinary tract infection.

CT requires exposure to radiation similar to an x-ray, so the patient’s provider and

radiologist should be notified promptly of the possibility of pregnancy. The other conditions
do not preclude CT scan examination for the patient.
 21. The nurse is caring for an elderly patient with a history of arthritis, urinary
incontinence and poor perineal hygiene practices. The patient has had four
urinary tract infections in the past year. Which is the priority goal for the nursing
diagnosis Impaired health maintenance for this patient?
a. The patient will be provided with educational materials about risks of
urosepsis.
b. The patient will allow family members to assist with daily bathing and perineal
care.
c. The patient will discuss the possible consequences of frequent UTIs.
d. Regular home care nursing visits and follow-up telephone contact will be
arranged.

The priority for this patient is to improve personal hygiene and perineal care in order to
reduce the risk of future urinary tract infections. The patient’s agreement to allow family
members to assist with bathing and perineal care will greatly reduce this risk. Providing
educational materials about the risk of urosepsis, discussion of UTI consequences, and
regular follow-up care are interventions rather than patient goals.

22. The nurse is caring for an elderly patient whose dementia has become worse
over the last 24 hours. The nurse suspects that the patient may have developed
a urinary tract infection and obtains a urine sample. Which assessment findings
prompt the nurse to contact the provider to obtain an order for urine culture and
sensitivity testing? (Select all that apply.)
a. Urinary dipstick testing is positive for nitrates.
b. The urine appears cloudy with a foul odor.
c. The urine is concentrated and dark amber in color.
d. The urine smells faintly like sweet fruit.
e. The patient is urinating more frequently than usual.
f. The patient is normally continent but has been incontinent twice.

Concentrated dark urine indicates dehydration rather than infection of the urinary tract.
Urine that smells of sweet fruit contains ketones from high blood sugar. Urine that is cloudy
with a foul odor and positive for nitrites is most likely due to urinary tract infection. Frequent
urination and incontinence are signs of urinary tract infection in the elderly.

23. The nurse is caring for a male patient who will be performing intermittent self-
catheterization at home. Which actions by the patient indicate the need for
additional teaching about this procedure? (Select all that apply.)
a. Patency of the balloon is tested prior to insertion of the catheter.
b. The catheter is inserted another 2 inches after urine is seen in the tubing.
c. The catheter is carefully secured to the leg to prevent accidental removal.
d. The foreskin is returned to its natural position after the catheter is removed.
e. Catheterization is performed regularly before the bladder becomes distended.
f. Water-soluble lubricant is generously applied along the length of the catheter.
Only 5 to 8 inches of the catheter tip are covered with water-soluble lubricant. Patency of the
balloon is only checked when indwelling catheters are inserted. Intermittent catheters need
not be secured to the patient’s leg because they will be removed after the bladder is
drained. The other actions are correct.

24. The nurse is working with a new nursing assistant who is providing care to
patients with urinary difficulties. Which actions by the nursing assistant indicate
that additional teaching is required? (Select all that apply.)
a. The length of the urinary catheter is cleaned up to the patient’s perineum.
b. A urine sample is obtained from the drainage bag immediately after catheter
insertion.
c. A fresh condom catheter is applied every other day following careful perineal
care.
d. Zinc oxide barrier cream is applied liberally to the perineal area for incontinent
patients.
e. The catheter drainage bag is disconnected in order to put pants on the
patient.
f. Clean technique is used to obtain a urine specimen for culture and sensitivity
from the catheter.

The urinary catheter must be cleaned from the urinary meatus down toward the drainage
bag rather than up toward the perineum. A fresh condom catheter must be applied daily.
The catheter drainage bag should not be disconnected to put pants on the patient. The
drainage bag can be threaded through the pants leg before putting pants on the patient.
Sterile technique should be used to obtain samples from the catheter.

25. The nurse is caring for a patient who is to complete a 24-hour urine collection to
measure creatinine clearance. Which tasks related to this test may be delegated
to the nursing assistant? (Select all that apply.)
a. Teaching the patient about sterile specimen collection
b. Keeping the urine collection container cool on ice
c. Dumping the urine from the patient’s first void
d. Restricting the patient’s oral fluid intake during the test
e. Transporting the specimen to the laboratory for testing
f. Reminding the patient not to put toilet paper in the urine

The nurse assistant can help the nurse by keeping the urine collection container cool on ice,
dumping the urine from the patient’s first void, and reminding the patient not to put toilet
tissue in the urine specimen. The nurse assistant can also transport the specimen to the
laboratory after the urine has been collected for 24 hours. Fluid intake should be encouraged
during the test. Teaching the patient about the testing procedure is done by the nurse,
although creatinine clearance testing does not require sterile technique.

Linton CH.14 Quizlet