Chapter 19: Urinary Elimination

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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation 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.

2. The nurse inserts an indwelling urinary catheter into an adult patient who has been unable to void. Which assessment finding would the nurse expect?

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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment 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.

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?

ANS: D

Patient reports of frequency and urgency are consistent with clinical indicators of a bladder infection, which indicates that the intermittent catheterization has been ineffective. Follow-up nursing interventions include increasing patient fluids to dilute and flush out urinary pathogens and collaborating with the provider for potential alterations to the therapeutic regimen, including urine culture and sensitivity. If the patient passes urine in the bathroom, he or she has enough bladder control to reach the bathroom before urinating, which is consistent with clinical indicators of normal urinary function. Normal urine is clear, yellow, and without strong odors and indicates that intermittent urinary catheterization is effective therapy. A nonpalpable bladder indicates an empty bladder and effective intermittent urinary catheterization.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Prone b. Supine c. High-Fowler’s d. Dorsal recumbent

4. In which position would the nurse place a female patient when preparing to insert a urinary catheter?

ANS: D

The nurse assists the female patient to the dorsal recumbent position for insertion of a urinary catheter because this position exposes the perineum adequately to visualize the urinary meatus and maintain aseptic technique during the procedure. Positioning the patient on her stomach, flat in bed, or sitting upright impairs the nurse’s ability to expose the perineum, visualize the urinary meatus, maintain aseptic technique, and drain urine from the bladder.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Rinse the perineum with warm antiseptic solution. b. Swab the perineum 3 times from the anus to the urinary meatus. c. Use the nondominant hand to keep the labia spread apart continuously. d. Use the nondominant hand to cleanse from the urinary meatus to the rectum.

5. Which technique does the nurse use to cleanse the perineum of a female patient during urinary catheter insertion?

ANS: C

The nurse uses the nondominant hand to spread apart the labia and maintain the position until the catheter is in place; once the nurse contaminates the nondominant hand by touching the perineum, he or she cannot use that hand to manipulate sterile equipment. Rinsing the perineum is impractical and not necessary. To prevent infection, the nurse uses the dominant hand to cleanse from the urinary meatus to the rectum in one motion.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The patient urinates at least every 4 hours. b. The patient’s urine is dark yellow and clear. c. The skin of the penis under the catheter is dusky. d. The patient applies the catheter independently.

6. The nurse is changing an external urinary catheter on a male patient. Which observation by the nurse requires additional attention?

ANS: C

Regardless of the location, dusky skin is cause for concern because it is a clinical indicator of tissue hypoxia. If the tissue is hypoxic, the perfusion is probably inadequate to meet tissue oxygen demand and increases the risk of skin breakdown. Urinating at least every 4 hours is a desirable outcome. Clear, light yellow urine is a desirable outcome because it indicates urine that is free of sediment and not infected. Ability to perform self-care for a urinary catheter depends on the physical abilities and motivation of the patient, but it is generally a desirable outcome.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Retract the foreskin of the penis before applying the catheter. b. Remove the hair at the base of the penis before applying the catheter. c. Apply a petroleum-based skin barrier to the penis first. d. Press the catheter adhesive to encourage adherence to the penis.

7. Discharge teaching for a male patient with an external urinary catheter would include which of the following instructions?

ANS: D

The nurse would instruct the patient to squeeze around the penis gently to firmly secure the adhesive to the penis to prevent leaking. Retracting the foreskin before applying an external catheter and removing the hair at the base of the penis are not indicated. Applying a petroleum-based product impairs the ability of the adhesive to adhere to the skin.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Check the catheter tubing for an obstruction. b. Ask the patient if he or she feels the urge to void. c. Notify the provider of inadequate urine output. d. Increase the patient’s fluid intake over the next hour.

8. Four hours after applying an external urinary catheter, the nurse observes no urine output in the drainage bag. Which intervention does the nurse implement first?

ANS: B

Ask the patient if he or she senses the urge to void because it may indicate a full bladder. The patient can also have urinary retention with an urge to void but no urine output. If the patient states that he has no urge to void, the nurse can scan the bladder to evaluate its contents. Catheter tubing kinks do not affect the flow of urine with an external urinary catheter in the same way they would if an indwelling catheter were used. There could be some wetting of the perineum with leakage if the catheter tubing is kinked. The nurse would not notify the health care provider until performing patient assessment. Increasing the patient’s intake can be contraindicated but can be effective to increase urine output.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Keep the foreskin over the penis tip. b. Use long strokes down the shaft of the penis. c. Hold the penis at a right angle to the body. d. Hold the cotton balls in the dominant hand.

9. The nurse set up the sterile field and is preparing to cleanse a male patient before inserting a urinary catheter. What step is essential for the nurse to use when cleaning the penis?

ANS: C

The nurse uses the nondominant hand to hold the penis at a right angle to the body for cleansing so the dominant hand remains sterile to insert the catheter. The nurse retracts the foreskin during cleansing because the meatus is covered partially by the foreskin; the only method of cleansing the meatus is to retract the foreskin. Cleansing the shaft of the penis is unnecessary. The cotton balls remain on the sterile field until needed by the nurse.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Deflate the balloon. b. Remove the catheter. c. Advance the catheter 2 inches. d. Reassure the patient that it will pass.

10. The patient reports a sharp stabbing pain when the nurse inflates the balloon during insertion of an indwelling urinary catheter. What would the nurse do in response to the patient report of pain?

ANS: A

The nurse deflates the balloon promptly because the balloon inflation precipitated the pain. The balloon is probably still in the urethra. It had not been inserted far enough into the patient. It is unnecessary to remove the catheter. After deflating the balloon, the nurse advances the catheter by 2 inches or more before attempting reinflation. Simply reassuring the patient will not solve the problem.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Label the irrigation solution genitourinary (GU) irrigation only. b. Change the irrigation tubing at least once every 12 hours. c. Infuse the irrigation solution at 100 mL/hr for clear urine. d. Ensure that the patient has a triple-lumen urinary catheter.

11. The nurse reviews an order for a continuous bladder irrigation after prostate surgery. Which action does the nurse take before starting the bladder irrigation?

ANS: D

The nurse first confirms that the patient has a triple-lumen urinary catheter before beginning the irrigation. This type of catheter is usually placed while the patient is in the operating room. The nurse labels the irrigation solution properly according to agency policy for patient safety and to prevent inadvertent intravenous infusion. The nurse changes the irrigation tubing according to agency policy; every 12 hours is excessive and is likely to contribute to an infection. The nurse titrates the irrigation solution either to the provider’s order, to keep the drainage free of clots, or by agency policy.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. 550 mL b. 720 mL c. 3000 mL d. 3720 mL

12. The nurse infused a continuous bladder irrigation solution at 250 mL/hr for 12 hours. The total output amount measured was 3720 mL. What will the nurse record for the patient’s urinary output?

ANS: B

The nurse determines the patient’s urine output by subtracting the total volume of irrigation solution infused from the total urinary catheter output because the nurse infused and drained the irrigation solution.

Urinary drainage = 3720

Total of irrigation fluid = (12 hours  250 mL/hr) = 3000 Actual urine output = 720 mL

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. The catheter does not drain urine continuously. b. The catheter remains in the stoma at all times. c. The patient’s urine is dark yellow and without odor. d. The patient urinates a small volume from the urethra.

13. The nurse assesses a patient’s suprapubic catheter. Which observation warrants further investigation by the nurse?

ANS: A

The nurse expects the suprapubic urinary catheter to drain urine continuously; if the flow decreases or stops, the nurse suspects an obstruction or adherence of the catheter against the bladder wall. Regardless of the cause, the nurse investigates interrupted flow of urine to prevent infection, tissue trauma, and patient discomfort. The nurse expects the suprapubic catheter to stay in the stoma, the urine to be yellow and odorless, and the patient to urinate a small volume from the urethra.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Encourage the patient to change positions. b. Clamp the urinary catheter for 30 minutes. c. Contact the health care provider for a diuretic. d. Assess the patient’s intake and catheter patency.

14. The nurse determines that the patient’s urinary output from the suprapubic catheter is 150 mL for 8 hours. What does the nurse implement as a follow-up nursing intervention?

ANS: D

Before concluding that the patient’s urinary output is deficient, the nurse completes an assessment to eliminate inadequate intake and catheter obstruction as the potential causes of the low urine output. The nurse expected at least 240 mL of urine in 8 hours. Changing positions will not allow the catheter to drain more freely unless the tubing has been kinked by the patient’s body. Clamping the catheter is wholly counterproductive. The nurse needs to complete the urinary assessment before determining that a diuretic is suitable therapy for the patient; if a diuretic were proper, the patient would exhibit other clinical indicators of fluid volume overload such as crackles, edema, and jugular venous distention.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Apply an antiseptic ointment. b. Keep the suprapubic insertion site dry. c. Attach a different bag to the skin. d. Fit the stoma with a tight skin barrier.

15. The nurse assesses the patient’s skin around the suprapubic catheter and observes extremely reddened skin. Which is the best nursing intervention to promote skin integrity?

ANS: B

The best nursing intervention for reddened skin is to keep the area clean and dry. Reddened skin does not necessarily indicate infection; thus the antiseptic ointment can be contraindicated. The catheter drains into a bag and is not attached directly to the skin. There is no stoma when a patient has a suprapubic catheter.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Tell the patient to bear down. b. Ask the patient to inhale quickly. c. Apply force to insert the catheter. d. Remove the catheter immediately.

16. The nurse encounters resistance during the insertion of a urinary catheter in a male patient. Which action would the nurse implement first?

ANS: A

Having the patient bear down as if urinating relaxes the urinary sphincter, making catheter insertion easier. If the patient is not bearing down, doing so may eliminate any resistance Asking the patient to inhale quickly is counterproductive because it effectively creates a Valsalva maneuver and stiffens the sphincter muscle. To prevent tissue trauma, the nurse never applies force to insert a urinary catheter. Removing the catheter is premature until holding the tip against the sphincter has been tried to relax the muscle.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Catheterizing the patient b. Irrigating the catheter c. Obtaining a urine culture d. Providing catheter care

17. The nurse is making patient care assignments for the staff. Which elimination activity can the nurse delegate to nursing assistive personnel (NAP) for a patient with an indwelling urinary catheter?

ANS: D

The nurse delegates care of an indwelling urinary catheter to the NAP because the NAP is trained to perform this task as part of hygienic care. The nurse catheterizes the patient, irrigates a urinary catheter, and obtains a urine specimen for a culture because each task is a sterile procedure performed by the nurse.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Maintain slight tension on the tubing. b. Keep the collection bag several inches from the floor. c. Empty the collection bag every 24 hours. d. Clean the catheter from the meatus to the tubing.

18. A patient is going to have an indwelling catheter for the next few weeks as a result of postoperative complications. Which action does the nurse use to prevent the most common complication of an indwelling urinary catheter?

ANS: D

Cleansing the indwelling urinary catheter by using circular motions from the urinary meatus to the collection bag tubing decreases the microorganism count on the catheter and prevents a urinary tract infection. The nurse secures the catheter to the patient’s leg to prevent retrograde catheter movement into the bladder, which can introduce potential pathogens into the bladder and increases the risk of a urinary tract infection. The nurse keeps the urinary collection bag below the patient’s hips to facilitate drainage and prevent retrograde flow of urine to the bladder. The collection bag is emptied at least every shift to prevent infection by removing a potential source of bladder contamination.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Run a trickle of water in the bathroom. b. Apply a rolling motion over the bladder. c. Ask about voiding difficulties in the past. d. Instruct the patient to run warm water on the perineum.

19. The nurse notes that 8 hours after removing the patient’s indwelling urinary catheter, the patient has not voided. Which action would the nurse take first?

ANS: C

The nurse assesses the patient for a history of voiding difficulties, especially after removal of an indwelling catheter, and asks the patient about successful strategies that facilitated voiding. Patient difficulties often arise from the physical distortion of the urinary meatus and sphincters by the urinary catheter; after the urethra and sphincters return to normal and regional edema improves several hours later, the patient voids. Running water in the bathroom, running warm water over the perineum, and applying gentle pressure to the bladder are suitable techniques to stimulate urination after assessing the patient. But the nurse needs to assess the patient first.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Placing the adhesive from the kit to hold the catheter in place b. Checking the condition of the penis and scrotum before the procedure c. Providing perineal care before catheter placement d. Allowing a space between the tip of the penis and the catheter

20. The nurse delegates the application of an external urinary catheter to nursing assistive personnel (NAP), including application of an external urinary catheter. Which aspect of applying the external catheter must the nurse perform?

ANS: B

The nurse assesses the penis and scrotum before the NAP begins the procedure to establish baseline data. The nurse performs assessment tasks because assessing requires nursing judgment and planning skills. He or she delegates using adhesive to hold the catheter in place, providing hygiene, and allowing a space between the tip of the penis and the end of the catheter for urine flow because the NAP is trained to perform these elimination tasks.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Applies an external urinary catheter. b. Assists the patient to the upright position. c. Encourages the patient to void every hour. d. Instructs the patient to increase his fluid intake.

21. A male patient is having difficulty using the urinal in bed. What does the nurse do to facilitate voiding?

ANS: B

N

The nurse assists the patient into an upright position to facilitate voiding into a urinal because men are accustomed to voiding in a standing position. If sitting upright is ineffective and the patient can be upright without dizziness or weakness, the nurse assists the patient to dangle or to stand for urination into a urinal. Applying an external catheter facilitates containing the urine but should not be used as the first option. Voiding hourly or increasing fluid intake does not address the issue of the patient having difficulty voiding in bed.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Place the scanner head on the symphysis pubis using ultrasound gel. b. Set the gender designation on the scanner as “male.” c. Place the scanner head above the symphysis pubis without ultrasound gel. d. Set the gender designation on the scanner as “female.”

22. A female patient with a hysterectomy now needs to have her bladder scanned because of difficulty voiding after back surgery. What action does the nurse take to obtain the most accurate scan?

ANS: B

Since the female reproductive organs are absent, the internal structure is similar to that of a male for bladder scanning purposes. The scanner head is placed above the symphysis pubis, not on the bone. Ultrasound gel and the area above the symphysis pubis are used. The female gender designation would be incorrect after a hysterectomy for bladder scanning purposes.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Enlist a sitter to keep the patient safe. b. Obtain an order for a urinalysis. c. Assess the patient’s intake and output. d. Check the patient’s recent lab data.

23. A nurse is caring for an older patient who is recovering from a serious illness. The patient has an indwelling urinary catheter. The nurse notes the onset of new confusion. What action by the nurse is best?

ANS: B

Older adults often do not exhibit the normal signs of urinary tract infections but may display changes in orientation and behavior. The nurse will contact the provider and request a urinalysis. A sitter may or may not be needed for safety. Assessing I&O and lab data may or may not be helpful, but with a catheter, the patient is at risk for developing a catheter associated urinary tract infection.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

Multiple Response

1. The nurse is reviewing the interventions for prevention of urinary catheter infections (CAUTIs). Which of the following interventions will help prevent infection? (Select all that apply.)

a. Maintain a closed system.

b. Perform routine perineal hygiene daily.

c. Only open the system when necessary.

d. Secure the catheter to prevent pulling on the catheter.

e. Maintain an unobstructed flow of urine.

ANS: A, B, D, E

Evidence-based interventions to prevent CAUTIs include maintaining a closed system; performing perineal care daily, or as needed; securing the catheter to prevent pulling; and maintaining an unobstructed flow of urine. The system would not be opened.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Patient reports pain at the site or when voiding. b. Redness or irritation at the site where the condom catheter is applied. c. Skin breakdown of the glans penis or penile shaft. d. Inability to apply the catheter. e. Urinary incontinence.

2. The nurse is providing instructions to the NAP on applying a condom catheter on a male patient. Which of the following does the nurse instruct the NAP to report? (Select all that apply.)

ANS: A, B, C, E

Patient reports of pain and any skin irritation or breakdown should be immediately reported to the nurse for follow-up. If the patient has retracted anatomy, the nurse can choose to apply a different type of external urine collection device. The reason for the condom catheter is for urinary incontinence and therefore would not need to be reported.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. “I should shave the pubic hair first.” b. “With my dominant hand, I hold the rolled condom sheath.” c. “I allow 1–2 inches of space between the tip of the penis and the end of the condom.” d. “I should not use any additional adhesive tape around the penis.” e. “I should first provide perineal care.”

3. The nurse is reviewing the instructions for applying a condom catheter with the NAP. Which of the following statements indicates an understanding of the procedure? (Select all that apply.)

ANS: B, C, D, E

Perineal care is completed and then the hair is clipped, not shaved. The nondominant hand holds the penis while the dominant hand holds the condom. The securing device supplied by the manufacturer is used. One to two inches of space is left at the tip of the penis and the end of the condom.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Evaluation a. Frequently incontinent b. On high dose steroids c. Receiving fluid resuscitation for burns d. Critically ill e. On hospice, for comfort

4. The charge nurse is reviewing patients on the unit who have indwelling urinary catheters for appropriateness of this treatment. Which of the following have catheters for appropriate reasons? (Select all that apply.)

ANS: C, D, E

Appropriate reasons for using a catheter include high volumes of fluids, critically ill needing close monitoring of intake and output, and for comfort care at the end of life. A patient who is frequently incontinent or one receiving high doses of steroids does not need a catheter.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation