Urinary Patterns Case Study – Flashcards

Clyde Hunter, a 72-year-old African-American male, is a resident of a long-term care facility. He has been unable to control the urge to void since experiencing a stroke, formerly called cerebrovascular accident (CVA), 1 month ago. The term brain attack is also used to describe a stroke. 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? A. Dysuria B. Frequency C. Nocturia D. Diureses

2. Since Clyde now voids spontaneously without recognizing the need to void, how should the nurse describe his current urinary pattern? A. Polyuria B. Incontinence C. Retention D. Oliguria

The nurse initiate a bladder training program for Clyde. 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.

The bladder-training program proves unsuccessful, and Clyde's incontinence continues. 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.

Following an incontinent episode, the nurse observes that the UAP washed the client's perineal area with mild soap and water and applies a water-repellant ointment to the skin exposed to urine. 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.

The nursing staff continues with the bladder-training program, but Clyde's incontinence shows little improvement. Since the bladder training has not been successful, the nurse obtains a prescription to apply a condom catheter. Clyde is ambulatory with assistance. 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.

Clyde is admitted to the acute care facility for minor surgery. His preoperative prescriptions include insertion of an indwelling urinary catheter. A student nurse assigned to care for his obtains a catheter insertion tray that includes a 22 Foley catheter with a 5 ml ballon. Since the student's instructor is busy, the staff nurse preceptor with supervise the student. 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.

The nurse reviews factors that may impact catheter insertion with the student. 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 student obtains a 16 Foley catheter from the supply room. She explains the procedure to Clyde, who gives her permission to begin. After cleansing the urinary meatus, the student nurse maintains sterile technique while inserting the catheter into the urethra about 4 inches and inflating the balloon. Clyde cries out in obvious pain. 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 is successfully placed in the bladder with a return of 200 ml of clear, yellow urine. The catheter is secured, and Clyde is resting comfortably. 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.

Clyde returns from the Post Anesthesia Care Unit (PACU). He has an IV of LR infusing at 150 ml/hr, O2 at 2 L/min per nasal prongs, and the indwelling catheter attached to a drainage bag. Clyde is responsive but confused and frequently pulls on the urinary catheter. The nurse observes obvious hematuria in the drainage bag and notes the presence of several blood clots in the tubing. 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.

Clyde's hematuria continues. Two hours later, he becomes restless and appears to be in pain. The nurse observes that there has been no urinary output in the last 2 hours. 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 nurse is unable to resolve the catheter obstruction using noninvasive measure and notifies the healthcare provider, who prescribes bladder irrigation to dislodge ay blood clots obstructing the urine flow. 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.

The nurse encourages the nursing student to perform the irrigation. The student prepares the solution, applies gloves, clamps the distal tubing, and begins to clean the specimen port on the drainage tubing. 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 instills a total of 60 ml of the correct solution and withdraws 40 ml of fluid containing several small blood clots. The student then empties 200 ml from the urinary drainage bag. 15.What output should be recorded? (Numerical value only, if rounding, round to whole number.)

During the catheter irrigation, the nurse observes that Clyde is still confused and attempts to pull at his catheter, his IV, and his nasal cannula. 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.

After obtaining a prescription for wrist restraints, the nurse applies the restraints and plans to monitor the client every 30 minutes. 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.

18. Which should the nurse implement? 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.

After 24 hours of receiving the antibiotic, Clyde's condition has not improved. Urinalysis results are: pH 8.5 Specific gravity 1.015 Protein none Glucose none WBCs 8 RBCs 2 Bacteria present 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.

20. What diagnostic test result ID's the client as being at risk for sepsis? 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.

After reviewing Clyde's diagnostic test results, the nurse consults with the healthcare provider and receives a prescription for a new antibiotic. 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.

The nurse notes that the medication dosage is in the safe range for elderly clients. The medication is to be administered by IV every 12 hours. 22. The nurse recognized that the frequency of drug administration is based on which characteristic of the medication? A. Bioavailability. B. Protein binding. C. Therapeutic index. D. Half-life.

Clyde's indwelling catheter is removed by the nurse on the morning of Clyde's anticipated discharge. 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

To encourage voiding, the nurse instructs the UAP to perform what intervention? 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.

Clyde is discharged from the acute care facility and is transferred to the long-term care facility. Since he no longer has an IV, the prescription for his antibiotic is changed to an oral medication. Clyde has some difficulty swallowing (dysphagia), and the nurse is considering the best technique to help Clyde swallow the medication. 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?

The nurse determines that the capsule can be opened and mixed with a food that the client likes. 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.

Clyde's incontinence continues. Use of the condom catheter is resumed until Clyde develops localized dermatitis. The condom catheter is removed temporarily to promote healing, and although the nursing staff takes Clyde to the bathroom every 2 hours, he occasionally wets his clothing. The nurse enters Clyde's room and finds him crying. 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.

When Clyde is calm, the nurse assigns the UAP to help him into dry clothing. Several minutes later, the nurse walks down the hall and sees the UAP in the room changing Clyde's clothes. The nurse enters the room and assesses the situation. 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.

Clyde continues to reside at the long-term care facility. While his incontinence continues, the use of the condom catheter and other nursing interventions make it possible for him to enjoy daily activities and socialize with other residents.