Fundamentals of Nursing Practice Quiz 14

Answer: C – Prostate enlargement

Explanation: An enlarged prostate compresses the urethra and interferes with the outflow of urine, resulting in urinary retention. With urinary retention, the pressure within the bladder builds until the external urethral sphincter temporarily opens to allow a small volume (25-60mL) of urine to escape (overflow incontinence). Coughing, which raises the intro abdominal pressure, is related to stress incontinence, not overflow incontinence. Mobility deficits, such as spinal cord injuries, are related to reflex incontinence, not overflow incontinence.

Answer: B – Graduate

Explanation: A graduate is a collection container with volume markings usually at 25 mL increments that promote accurate measurements of urine volume. Although urinals have volume markings on the side, usually they occur in 100 mL increments that do not promote accurate measurements is impractical.

Answer: B – Urinary tract infection

Explanation: The urine appears concentrated (amber)and cloudy because of the presence of bacteria, white blood cells, and red blood cells. The unpleasant odor is caused by pus in the urine (pyuria). These clinical manifestations do not reflect urinary retention. Urinary retention is evidenced by supra pubic distention and lack of voiding or small, frequent voiding (overflow incontinence) .

Answer: C – Positioning a bedside commode near the bed

Explanation: The use of a commode requires less energy than using a bedpan and is safer than walking to the bathroom. Sitting on the commode uses gravity to empty the bladder fully and thus prevent urinary stasis. Although, should be done, it is not the priority, may be too often or not often enough for the patient. Care should be individualized for the patient.

Answer: A – Use a sterile specimen container.

Explanation: A culture attempts to identify the microorganisms present in the urine, and a sensitivity study identifies the antibiotics that are effective against the isolated micro organisms. A sterile specimen container is used to prevent contamination of the specimen by micro organisms outside the body (exogenous).

Answer: A – Check to see whether the catheter is patent

Explanation: A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate. Reassuring the client that is not possible to urinate is a non-therapeutic response because it diminishes the client’s concern, There are less invasive approaches the nurse can take before replacing the catheter, Although it may become necessary to collect a urine specimen, there is a simpler approach the nurse can take to assess and possibly resolve the client’s problem.

Answer: A – Discard the first voiding

Explanation: The nurse should discard the first voiding of the 24 hour urine specimen, and note the time. The nurse should collect all voidings after that and keep them in a refrigerated container, For a urinalysis, the nurse should ask the client to urinate and pour the urine into a specimen container For a culture, the nurse should ask the client to urinate first into the toilet, then stop midstream, and finish urinating in the specimen container.

Answer: A – Constipation

Explanation: Habitually ignoring the urge to defecate can lead to constipation through loss of the natural urge and the accumulation of feces. Diarrhea will not result-if anything, there is increased opportunity for water reabsorption because the stool remains in the colon, leading to firmer stool. Ignoring the urge shows a strong voluntary sphincter, not a weak one that could result in incontinence. Hemorrhoids would only occur only if severe drying out of the stool occurs, and thus repeated need to strain to pass stool.

Answer: B – “I need to take a laxative such as milk of magnesia or if I don’t have a BM every day”

Explanation: The standard of practice in assisting the older adults to maintain normal function of the gastrointestinal tract is regular ingestion of a well-balanced diet, adequate fluid intake, and regular exercise. If the bowel pattern is not regular with these activities, this abnormality should be reported. Stimulant laxatives can be very irritating and are not the preferred treatment for occasional constipation in older adults. In addition, a normal stool pattern for an older adult may not be daily elimination.

Answer: D – Low, small volume

Explanation: Small volume enemas along with other preparations are used to prepare the client for this procedure. An oil retention enema is used to soften hard stool. Return flow enemas help expel flatus because of the risk of loss of fluid and electrolytes high,large volume enemas are seldom used.