TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 19: Urinary Elimination Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. The nurse is preparing to insert an indwelling urinary catheter into a female patient who is
having major open-heart surgery and will be in the intensive care unit after surgery. Which statement about the purpose of the catheter by the patient best indicates that teaching by the nurse was effective? a. “An empty bladder always helps prevent bladder infections.” b. “The catheter drains residual urine in case you get a urinary obstruction.” c. “The catheter prevents urinary infections.” d. “The catheter allows us to monitor your urine output closely after surgery.” ANS: D
During acute illness, a patient may require urinary catheterization for close monitoring of urine output or to facilitate bladder emptying when bladder function is compromised. An empty bladder does help prevent bladder infections by decreasing the risk of residual urine; however, a bladder infection is not as immediate a threat to the patient as fluid and electrolyte imbalance. A urinary catheter drains urine from an obstruction, but this is not this patient’s problem. The catheter does not prevent urinary infections. DIF: Cognitive Level: Understanding TOP: Nursing Process: Implementation
OBJ: NCLEX: Physiological Integrity
2. The nurse inserts an indwelling urinary catheter into an adult patient who has been unable to
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void. Which assessment finding would the nurse expect? a. The patient complains of burning. b. The urine output exceeds 30 mL in the first hour. c. The patient develops a fever. d. The urine is yellow and blood tinged. ANS: B
The nurse expects the catheter to drain more than 30 mL of urine in the first hour as an indication of adequate urine output because it has been a while since the patient voided. A patient complaint of burning or the development of a fever would be unexpected findings and warrant further assessment. Blood-tinged urine would also be an unexpected finding and warrant further assessment. DIF: Cognitive Level: Understanding TOP: Nursing Process: Assessment
OBJ: NCLEX: Physiological Integrity
3. The nurse evaluates the effectiveness of the patient’s intermittent urinary catheterization for
residual urine. Which of the following requires follow-up nursing intervention? a. The patient is passing urine in the bathroom. b. The urine is clear yellow and without odor. c. The bladder is nonpalpable above the pubic bone. d. The patient reports frequency and urgency. ANS: D
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