A 75-year-old client admitted with urinary retention is prescribed an indwelling urinary catheter. Which intervention is most appropriate to maintain urinary elimination and prevent infection? A. Change the catheter bag every 24 hours. B. Empty the catheter bag when half full. C. Cleanse the perineal area with soap and water daily. D. Secure the catheter tubing to the bedsheet. E. Ensure the catheter drainage bag hangs below the level of the bladder.
Correct Answer: E. Ensure the catheter drainage bag hangs below the level of the bladder.
Rationale: Proper positioning of the drainage bag below the bladder level prevents backflow of urine, reducing the risk of urinary tract infections (UTIs). Changing the catheter bag at set intervals, emptying it when half full, and securing tubing may be necessary but are not the primary interventions to prevent infection. Daily cleansing of the perineal area is essential for hygiene but doesn’t directly relate to catheter position.
60-Day NCLEX Challenge
NCLEX Review: Urinary Elimination Treatments
A client with a urinary tract infection (UTI) presents with dysuria and urgency. Which nursing intervention helps promote urinary elimination and comfort? A. Encourage cranberry juice intake. B. Limit fluid intake to decrease bladder irritation. C. Apply heat to the lower abdomen. D. Instruct the client to delay voiding as much as possible. E. Administering a mild diuretic.
Correct Answer: C. Apply heat to the lower abdomen.
Rationale: Applying heat to the lower abdomen can alleviate discomfort by relaxing bladder muscles and reducing spasms. Cranberry juice can aid in preventing UTIs but doesn’t directly relieve current symptoms. Limiting fluids can worsen symptoms by concentrating urine, and delaying voiding may exacerbate discomfort. A diuretic could increase urine output but may not alleviate dysuria or urgency.
1000 Medical-Surgical Questions
NCLEX Questions Critical Thinking: Urinary Elimination Symptoms
A postoperative client had a urethral catheter removed. What is the priority nursing action to promote urinary elimination? A. Encourage increased intake of caffeinated beverages. B. Instruct the client to avoid urinating for 6 hours. C. Assess for bladder distention and urinary retention. D. Administer a mild laxative to stimulate bowel movements. E. Encourage ambulation every 2 hours.
Correct Answer: C. Assess for bladder distention and urinary retention.
Rationale: Assessing for bladder distention and urinary retention is essential post-catheter removal to prevent complications. Increased intake of caffeinated beverages or avoiding urination may stress the bladder. Administering a laxative or encouraging ambulation, while important for overall recovery, does not directly address urinary elimination after catheter removal.
Understanding Urinary Elimination Care: NCLEX Delegation Questions
A 50-year-old male client is admitted with urinary incontinence due to an enlarged prostate. Which nursing intervention is most appropriate to manage his urinary elimination problem? A. Encourage decreasing daily water intake. B. Teach pelvic floor exercises (Kegels). C. Limit bathroom access to specific times. D. Provide a bedside commode for convenience. E. Suggest holding urine to strengthen the bladder.
Correct Answer: B. Teach pelvic floor exercises (Kegels).
Rationale: Pelvic floor exercises (Kegels) help strengthen the muscles controlling urinary flow, potentially improving incontinence related to an enlarged prostate. Decreasing water intake may worsen dehydration and concentrate urine, exacerbating the issue. Limiting bathroom access or advising holding urine can strain the bladder and worsen incontinence. Providing a bedside commode supports convenience but doesn’t address the underlying issue.
4000 Free NCLEX Questions
A 60-year-old female client with a history of diabetes presents with urinary frequency and burning. The urinalysis confirms a urinary tract infection (UTI). Which nursing intervention is essential for promoting urinary elimination in this client? A. Encourage increased intake of sugary drinks. B. Limit physical activity to conserve energy. C. Advocate for voiding every 4-6 hours. D. Apply an ice pack to the perineal area. E. Administer antibiotics as prescribed.
Correct Answer: E. Administer antibiotics as prescribed.
Rationale: Antibiotics are crucial in treating UTIs by eradicating the bacterial infection. Increased intake of sugary drinks can exacerbate UTI symptoms. Limiting physical activity might impede recovery. Advocating for regular voiding intervals is generally helpful but not as critical as treating the infection. Applying an ice pack isn’t a standard treatment for UTIs.
1000 AANP Questions
A postoperative client had a urinary catheter removed and reports difficulty urinating. Which nursing action best supports the client’s urinary elimination? A. Encourage drinking more caffeine. B. Instruct to limit fluid intake. C. Provide privacy and run water. D. Apply pressure to the lower abdomen. E. Advocate for immediate re-catheterization.
Correct Answer: C. Provide privacy and run water.
Rationale: Providing privacy and running water can stimulate relaxation and initiate the micturition reflex, aiding in urinary elimination. Encouraging more caffeine or limiting fluids may disrupt urine production or concentrate urine, worsening the issue. Applying pressure to the lower abdomen might cause discomfort. Re-catheterization should be a last resort and not an immediate action unless clinically necessary due to complications.
Free NCLEX Q-Bank 1400 Q&A
A 70-year-old client with a history of kidney stones is admitted to the hospital. The client reports severe flank pain and difficulty urinating. The nurse observes the client’s urine output is decreased. What action should the nurse prioritize? A. Encourage increased fluid intake. B. Administer an over-the-counter pain reliever. C. Apply a heating pad to the abdomen. D. Assist the client to lie flat on the affected side. E. Notify the healthcare provider immediately.
Correct Answer: E. Notify the healthcare provider immediately.
Rationale: Decreased urine output coupled with severe flank pain in a client with a history of kidney stones could indicate a potential obstruction or complication. Notifying the healthcare provider promptly is crucial to assess and address the situation. While increasing fluid intake is generally beneficial for kidney stones, it’s not the immediate priority in this case. Pain relief and heat application might provide comfort but do not address the potential obstruction.
1000 HESI Exit Questions
NCLEX Questions: Focus on Medications for Urinary Elimination
A client is receiving intravenous fluids and reports a sensation of needing to urinate frequently. The nurse notices the client’s urinary output is higher than the intake. Which action should the nurse take first? A. Assess the client for signs of dehydration. B. Encourage the client to limit fluid intake. C. Measure the client’s intake and output accurately. D. Decrease the intravenous fluid infusion rate. E. Obtain a urine specimen for analysis.
Correct Answer: C. Measure the client’s intake and output accurately.
Rationale: Accurate measurement of intake and output helps identify any discrepancy and ensures proper monitoring of fluid balance. While assessing for dehydration and obtaining a urine specimen are important, measuring intake and output accurately takes precedence to assess the situation. Encouraging the client to limit fluid intake or decreasing the IV infusion rate might be necessary actions based on findings but shouldn’t be the immediate first step.
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NCLEX Focus Exploring Urinary Elimination: Causes and Diagnosis
A client with a urinary catheter develops fever and reports lower abdominal discomfort. On assessment, the nurse observes cloudy and foul-smelling urine in the drainage bag. What action should the nurse take initially? A. Administer an analgesic for pain relief. B. Increase the frequency of catheter irrigation. C. Assess vital signs and notify the healthcare provider. D. Apply a warm compress to the lower abdomen. E. Encourage increased oral fluid intake.
Correct Answer: C. Assess vital signs and notify the healthcare provider.
Rationale: Cloudy, foul-smelling urine and signs of infection (fever, lower abdominal discomfort) in a client with a catheter raise concerns about urinary tract infection or catheter-related issues. Assessing vital signs and promptly notifying the healthcare provider is crucial for timely intervention. Pain relief, warm compress application, and increased fluid intake are supportive measures but don’t address the potential infection or underlying cause.
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Understanding Urinary Elimination: NCLEX Priority Questions
A postoperative client is experiencing urinary retention after the removal of a urinary catheter. The nurse attempts to encourage voiding without success. What should the nurse do next? A. Insert a new urinary catheter. B. Encourage the client to drink caffeinated beverages. C. Apply gentle pressure over the bladder. D. Instruct the client to ignore the urge to void. E. Notify the healthcare provider for further evaluation.
Correct Answer: E. Notify the healthcare provider for further evaluation.
Rationale: In the case of urinary retention post-catheter removal, if attempts to facilitate voiding fail, notifying the healthcare provider for further evaluation and possible intervention is essential. Inserting a new catheter without provider orders may not be indicated and requires assessment by the healthcare provider. Encouraging caffeinated beverages, ignoring the urge to void, or applying pressure over the bladder can be counterproductive or uncomfortable for the client.
