Nursing Chapter 48 Rationale The Hands And Sense Touch Are

Kozier & Erb’s Fundamentals of Nursing, 10/E

Chapter 48

Question 1

Type: MCSA

The nurse is assessing a client’s urinary elimination. Which factor should the nurse keep in mind as influencing

this elimination?

1. Age

2. Body image

3. Knowledge

4. Socioeconomic status

Question 2

Type: MCSA

The nurse realizes that which client is at risk for difficulty in urinary elimination?

1. A client who had bladder cancer and now has a newly created ileal conduit

2. A 25-year-old female client with low self-esteem

3. An 80-year-old male reporting frequent urination at night

4. The client with hypertension who takes a diuretic every day for blood pressure

Question 3

Type: MCSA

A client tells the nurse about the need to get up several times throughout the night to void. The nurse suspects the

client is experiencing nocturia due to which factor?

1. Decrease in bladder tone

2. Decrease in blood supply

3. Decrease in number of nephrons

4. Decrease in cardiac output

Question 4

Type: MCSA

Which intervention would the nurse plan to help a client prevent a urinary tract infection?

1. Encourage the use of bubble baths.

2. Have the client increase sugar in the diet.

3. Instruct the client to empty the bladder completely.

4. Wipe from back to front.

Question 5

Type: MCSA

The nurse should incorporate which instructions into the teaching plan for a client with a urinary diversion?

1. Change the appliance several times a day.

2. Increase fluid intake.

3. Notify the physician if the stoma is deep pink and shiny.

4. Strands of blood may appear in the urine.

Question 6

Type: MCSA

Which nursing intervention is appropriate when caring for a client with a retention catheter?

1. Don sterile gloves.

2. Gently retract the labia majora away from the urinary meatus.

3. Observe urine in the drainage bag.

4. Retape the catheter to the thigh.

Question 7

Type: MCSA

Which nursing diagnosis would be appropriate for a client who has a retention catheter if the drainage bag is

found lying on the floor?

1. Risk for Impaired Skin Integrity related to catheter placement

2. Risk for Infection related to improper handling

3. Self-Care Deficit related to presence of a retention catheter

4. Risk for Incontinence related to an obstruction

Question 8

Type: MCSA

The nurse is identifying outcomes for a client with the nursing diagnosis Stress Urinary Incontinence. Which

outcome would be related to sphincter incompetence?

1. The client will empty her bladder every time she voids.

2. The client will improve her incontinence within 1 month.

3. The client will perform four to five squeezes for 5 to 10 seconds.

4. The client will stop the flow of urine when voiding.

Question 9

Type: MCSA

Which goals should the nurse identify as appropriate for a client with the nursing diagnosis Urinary Pattern

Alteration related to an enlarged prostate?

1. The client will avoid bladder distention.

2. The client will maintain fluid imbalance.

3. The client will remain free of skin breakdown.

4. The client will voice increased discomfort.

Question 10

Type: MCSA

The RN is admitting a client to the medical unit for a urinary disorder. Which physical assessment techniques

should the nurse use in assessing this client’s urinary system?

1. Auscultation and inspection

2. Inspection and percussion

3. Observation and auscultation

4. Palpation and observation

Question 11

Type: MCSA

A client has been admitted with incontinence. What should the nurse expect to assess in this client?

1. Client is wearing cotton undergarments.

2. Leakage of urine occurs when client laughs.

3. Leakage of urine occurs when talking with the client.

4. The skin of the client is clear without discoloration.

Question 12

Type: MCSA

A client is rushed to the emergency department with what the physicians suspect to be necrosis of the urinary

diversion stoma. What evidence presented by the client leads to this conclusion?

1. Black with sloughing

2. Moist stoma

3. Pink and shiny

4. Slight bleeding from stoma

Question 13

Type: MCSA

A client’s results from a urinalysis are as follows: pH 5.2, gross cloudiness, WBC 10–15, glucose negative,

specific gravity 1.012, and protein negative. How should the nurse interpret the results?

1. Dehydration

2. Diabetic ketoacidosis

3. Trauma

4. Urinary tract infection

Question 14

Type: MCSA

A client’s urinalysis is reported as being normal. What were the client’s results?

1. Blood present and no ketones

2. Dark amber color and output less than 500 cc in 24 hours

3. pH 6 and no glucose present

4. Specific gravity 1.035 and faint aromatic odor

Question 15

Type: MCSA

A client is prescribed propranolol (Inderal). What should the nurse instruct the client about this medication?

1. The medication should be discontinued abruptly.

2. Notify the physician if you experience urinary retention.

3. Take a laxative every day.

4. Take the medication on an empty stomach.

Question 16

Type: MCSA

A client is having issues with urinary elimination. What should the nurse instruct this client to promote urinary

elimination?

1. Don’t interrupt your day by going to the bathroom; wait until you’re at a good stopping place.

2. Drink 8 to 10 glasses of water daily.

3. Urine color changes are not important.

4. Wash with soap and water every other day.

Question 17

Type: MCSA

A client is instructed on the care of an indwelling urinary catheter. Which returned demonstration by the client

indicates that teaching has been effective?

1. The client empties the drainage bag once a day.

2. The client hangs the drainage bag on the towel rod.

3. The client refuses drinks one to two 8-ounce glasses of fluid each day.

4. The client takes a shower each day.

Question 18

Type: MCSA

A client recovering from a transurethral resection of the prostate (TURP) with a three-way indwelling catheter

expresses the need to urinate. Which action should the nurse take to help this client?

1. Deflate and then reinflate the balloon.

2. Irrigate the catheter.

3. Reposition the catheter.

4. Retape the catheter to the abdomen.

Question 19

Type: HOTSPOT

The nurse is reviewing kidney function with a client experiencing renal failure. Identify the area in the nephron

where solutes such as glucose are reabsorbed.

Standard Text: Click on the correct area on the image.

Question 20

Type: MCSA

The nurse is caring for a client with a urinary diversion. For which type of diversion should the nurse plan care for

this client?