1. MCQs On Fundamentals of Nursing 2

2. 1. The nurse recognizes that urinary elimination changes may occur even in healthy older adults because of which of the following?
1. The bladder distends and its capacity increases 2. Older adults ignore the need to void 3. Urine becomes more concentrated 4. The amount of urine retained after voiding increases
The answer is : The amount of urine retained after voiding increases
The capacity of the bladder may decrease with age but the muscle is weaker and can cause urine to be retained (Option 4). Older adults don’t ignore the urge to void and may have difficulty getting to the toilet in time (Option 2). The kidney becomes less able to concentrate urine with age (Option3).

3. 2. During assessment of the patient with urinary incontinence, the nurse is most likely to assess for which of the following? Select all that apply.
1. Perineal skin irritation 2. Fluid intake of less than 1,500 mL/d 3. History of antihistamine intake 4. Hx of UTI 5. A fecal impaction
The answer is : 1, 2, 4, and 5
The perineum may become irritated by the frequent contact with urine (Opt1). Normal fluid intake is at least 1,500 mL/d and patients often decrease their intake to try to minimize urine leakage (Opt2). UTIs can contribute to incontinence (Opt4). A fecal impaction can compress the urethra, which results in sm. amts of urine leakage (Opt5). Antihistamines can cause urinary retention rather than urinary incontinence (Opt3).

4. 3. Which action represents the appropriate nursing management of a patient wearing a condom catheter?
1. Ensure that the tip of the penis fits snugly against the end of the condom 2. Check the penis for adequate circulation 30 min after applying 3. Change the condom every 8 hours 4. Tape the collecting tube to the lower abdomen.
The answer is : Check the penis for adequate circulation 30 min after applying
The penis and condom should be checked 1/2 hour after application to ensure that it’s not too tight. A 1 in. space should be left btw the penis and the end of the condom (opt1). The condom is changed every 24h (opt3) and the tubing is taped to the leg or attached to a leg bag. An indwelling catheter is taped to the lower abdomen or upper thigh (opt4).

5. 4. The catheter slips into the vagina during a straight catheterization of a female patient. The nurse does which action?
1. Leaves the catheter in place and gets a new sterile catheter 2. Leaves the catheter in place and asks another nurse to attempt the procedure 3. Removes the catheter and redirects it to the urinary meatus 4. Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary meatus
The answer is : Leaves the catheter in place and gets a new sterile catheter
The catheter in the vagina is contaminated and can’t be reused.If left in place, it may help avoid mistaking the vaginal opening for the urinary meatus. A single failure to catheterize the meatus doesn’t indicate that another nurse is needed although sometimes a second nurse can assist in visualization of the meatus (opt2).

6. 5. Which statement indicates a need for further teaching of a home care patient with a long term indwelling catheter?
1. “I will keep the collecting bag below the level of the bladder at all times” 2. “Intake of cranberry juice may help decrease the risk of infection” 3. “Soaking in a warm tub bath may ease the irritation associated with the catheter” 4. “I should use clean tech. when emptying the collecting bag”
The answer is : “Soaking in a warm tub bath may ease the irritation associated with the catheter”
Soaking in a bathtub can increase the risk of exposure to bacteria. The bag should be below the level of the bladder to promote proper drainage (opt1). Intake of cranberry juice creates an environment nonconducive to infection (opt2). Clean technique is appropriate for touching the exterior portions of the system (opt4).

7. 6. During shift report, the nurse learns that an older female patient is unable to maintain continence after she senses the urge to void and becomes incontinent on the way to the bathroom. Which nursing diagnosis is most appropriate?
1. stress urinary incontinence 2. reflex urinary incontinence 3. functional urinary incontinence 4. urge urinary incontinence
The answer is : urge urinary incontinence
The key phrase is “the urge to void” option one occurs when the patient coughs, sneezes, or jars the body, resulting in accidental loss of urine. Option two occurs with involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Option three is involuntary loss of urine related to impaired function.

8. 7. A female patient has a urinary tract infection
7. A female patient has a urinary tract infection. Which teaching points by the nurse should be helpful to the patient? Select all that apply.
1. Limit fluids to avoid the burning sensation on urination 2. Review symptoms of UTI with the patient 3. Wipe the perineal area from back to front 4. Wear cotton underclothes 5. Take baths rather than showers
The answer is : 2, 4
Option two validates the diagnosis. Cotton underwear promotes appropriate exposure to air, resulting in decreased bacterial growth (opt4). Increased fluids decrease concentration and irritation (opt1). The patient should wipe the perineal area from front to back to prevent spread of bacteria from the rectal area to the urethra (opt3). Showers reduce exposure of area to bacteria (opt5).

9. 8. The nurse will need to assess the patient’s performance of clean intermittent self catheterization (CISC) for a patient with which urinary diversion?
1. Ileal conduit 2. Kock pouch 3. Neobladder 4. Vesicostomy
The answer is : Kock pouch
The ileal conduit and vesicostomy (opt1,4) are in continent urinary diversions, and patients are required to use an external ostomy appliance to contain the urine. patients with a neobladder can control their voiding (opt3).

10. 9. Which focus is the nurse most likely to teach for a patient with a flaccid bladder?
1. Habit training: attempt voiding at specific time periods 2. Bladder training: delay voiding according to a pre-schedule timetable 3. Crede’s maneuver: apply gentle manual pressure to the lower abdomen 4. Kegel exercises: contract the pelvic muscles
The answer is : Crede’s maneuver: apply gentle manual pressure to the lower abdomen
Because the bladder muscles will not contract to increase the intra-bladder pressure to promote urination, the process is initiated manually. Options one, two, and four: to promote continence bladder contractions are required for habit training, bladder training, and increasing the tone of the pelvic muscles.

11. 10. Which of the following behaviors indicates that the patient on a bladder training program has met the expected outcomes? Select all that apply.
1. Voids each time there is an urge 2. Practices slow, deep breathing until the urge decreases 3. Uses adult diapers, for “just in case” 4. Drinks citrus juices and carbonated beverages 5. Performs pelvic muscle exercises
The answer is : 2, 5
It is important for the patient to inhibit the urge to void sensation when a premature urge is experienced. Some patients may need diapers; this is not the best indicator of a successful program (opt3). Citrus juices may irritate the bladder (opt4). Carbonated beverages increase diuresis and the risk of incontinence (opt4).

12. 11. A nurse has identified that the patient has overflow incontinence
11. A nurse has identified that the patient has overflow incontinence. What is a major factor that contributes to this clinical manifestation?
1. Coughing 2. Mobility deficits 3. Prostate enlargement 4. Urinary tract infection
The answer is : Prostate enlargement
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 (opt1). Mobility deficits, such as spinal cord injuries, are related to reflex incontinence, not overflow incontinence (opt2). Urinary tract infections are related to urge incontinence, not overflow incontinence (opt4).

13. 12. A nurse must measure the intake and output (I&O) for a patient who has a urinary retention catheter. Which equipment is most appropriate to use to accurately measure urine output from a urinary retention catheter?
1. Urinal 2. Graduate 3. Large syringe 4. Urine collection bag
The answer is : Graduate
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 (opt1). Option 3 is impractical. A large syringe is used to obtain a sterile specimen from a retention catheter (Foley catheter). A urine collection bag is flexible and balloons outward as urine collects. In addition, the volume markings are at 100 mL increments that do not promote accurate measurements (opt4).

14. 13. A patient’s urine is cloudy, is amber, and has an unpleasant odor
13. A patient’s urine is cloudy, is amber, and has an unpleasant odor. What problem may this information indicate that requires the nurse to make a focused assessment?
1. Urinary retention 2. Urinary tract infection 3. Ketone bodies in the urine 4. High urinary calcium level
The answer is : Urinary tract infection
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) (opt1). These clinical manifestations do not reflect Ketone bodies in the urine. A reagent strip dipped in urine will measure the presence of Ketone bodies (opt3). These clinical manifestations do not reflect excessive calcium in the urine. Urine calcium levels are measured by assessing a 24 hour urine specimen (opt4).

15. 14. A nurse is caring for a debilitated female patient with nocturia
14. A nurse is caring for a debilitated female patient with nocturia. Which nursing intervention is the priority when planning to meet this patient’s needs?
1. Encouraging the use of bladder training exercises 2. Providing assistance with toileting every four hours 3. Positioning a bedside commode near the bed 4. Teaching the avoidance of fluid after 5 PM
The answer is : Positioning a bedside commode near the bed
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 option 1 should be done, it is not the priority. Option 2 may be too often or not often enough for the patient. Care should be individualized for the patient. Fluids may be decreased during the last two hours before bedtime, but they should not be avoided completely after 5 PM (opt4). Some fluid intake is necessary for adequate renal perfusion.

16. 15. A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a patient. What should the nurse do when collecting this urine specimen?
1. Use a sterile specimen container. 2. Collect urine from the catheter port. 3. Inflate the balloon with 10 mL of sterile water. 4. Have the patient void before collecting the specimen.
The answer is : Use a sterile specimen container.
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). The urine from straight catheter flows directly into the specimen container. Collecting a urine specimen from a catheter port is necessary when the patient has a urinary retention catheter (opt2). A straight catheter has a single lumen for draining urine from the bladder. A straight catheter does not remain in the bladder and therefore does not have a 2nd lumen for water to be inserted into a balloon (opt3). This may result in no urine left in the bladder for the straight catheter to collect. A minimum of 3 mL of urine is necessary for a specimen for urine culture and sensitivity (opt4).

17. The answer is : 16. Answer: 2 and 4
16. A nurse in a provider’s office is assessing a patient who reports losing control of urine when ever she coughs, laughs, or sneezes. The patient relates a history of three vaginal births, but no serious accidents or illnesses. Which of the following interventions are appropriate for helping to control or eliminate the patients incontinence? Select all that apply.
1. Limit total daily fluid intake 2. Decrease or avoid caffeine 3. Increase the intake of calcium supplements 4. Avoid the intake of alcohol 5. Use Crede maneuver
The answer is : 16. Answer: 2 and 4
Caffeine and alcohol are bladder irritants and can worsen stress incontinence. Alcohol is a bladder irritant and can worsen stress incontinence. Because stress incontinence results from weak pelvic muscles and other structures, limiting fluid will not resolve the problem (opt1). Calcium has no effect on stress incontinence (opt3). The Crede maneuver helps manage reflex incontinence, not stress incontinence (opt5).

18. 17. A patient who has an indwelling catheter reports I need to urinate
17. A patient who has an indwelling catheter reports I need to urinate. Which of the following interventions should the nurse perform?
1. Check to see whether the catheter is patent 2. Reassure the patient that it is not possible for her to urinate 3. Re-catheterize the bladder with a larger gauge catheter 4. Collect a urine specimen for analysis
The answer is : Check to see whether the catheter is patent
A clogged or kinked catheter causes the bladder to fill and stimulates the need to urinate. Reassuring the patient that is not possible to urinate is a non-therapeutic response because it diminishes the patient’s concern (opt2). There are less invasive approaches the nurse can take before replacing the catheter (opt3). 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 patient’s problem (opt4).

19. 18. A provider prescribes a 24 hour urine collection for a patient
18. A provider prescribes a 24 hour urine collection for a patient. Which of the following actions should the nurse take?
1. Discard the first voiding 2. Keep all voidings in a container at room temperature 3. Ask the patient to urinate and pour the urine into a specimen container 4. Ask the patient to urinate into the toilet, stop midstream, and finish urinating into the specimen container
The answer is : 2 and 4
Caffeine and alcohol are bladder irritants and can worsen stress incontinence. Alcohol is a bladder irritant and can worsen stress incontinence. Because stress incontinence results from weak pelvic muscles and other structures, limiting fluid will not resolve the problem (opt1). Calcium has no effect on stress incontinence (opt3). The Crede maneuver helps manage reflex incontinence, not stress incontinence (opt5).

20. 19. A nurse is preparing to initiate a bladder training program for a patient who has a voiding disorder. Which of the following actions should the nurse take? Select all that apply.
1. Establish a schedule of voiding prior to meal times 2. Have the patient record voiding times 3. Gradually increase the voiding intervals 4. Reminded patient to hold urine until next scheduled voiding time 5. Provide a sterile container for voiding
The answer is : 2, 3, and 4
Ask the patient to keep track of voiding times is an appropriate nursing action. Gradually increasing the voiding interval is an appropriate nursing action. The patient should be reminded to hold urine until the next scheduled voiding time. Bladder training involves voiding at scheduled in frequent intervals and gradually increasing these intervals to four hours. Mealtimes are not regular, and the intervals may be longer than every four hours (opt1). A sterile container is not used in a bladder training program (opt5).

21. 20. A nurse educator on a medical unit is reviewing factors that increase the risk of urinary tract infections with a group of assistive personnel. Which of the following should be included in the review? Select all that apply.
1. Having sexual intercourse on a frequent basis 2. Lowering of testosterone levels 3. Wiping from front to back 4. The location of the vagina in relation to the anus 5. Undergoing frequent catheterization
The answer is : 1, 4, and 5
Having sexual intercourse on a frequent basis is a factor that increases the risk of UTI in both males and females. The close proximity of the female urethra to the anus is a factor that increases the risk of UTIs. Undergoing frequent catheterization and the use of indwelling catheters are risk factors for UTIs. The decrease in estrogen levels during menopause increases a woman’s susceptibility to UTIs (opt2). Wiping from front to back decreases a woman’s risk of UTIs (opt3).

22. The
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