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NUR 231 Exam 2 Questions and Answers 100% Solved

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NUR 231 Exam 2 Questions and Answers 100% Solved A patient is experiencing oliguria. Which action should the nurse perform first? a. Increase the patient's intravenous fluid rate. b. Encourage the patient to drink caffeinated beverages. c. Assess for bladder distention. d. Request an order f...

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  • November 1, 2024
  • 23
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers
  • NUR 231
  • NUR 231
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NUR 231 Exam 2 Questions and

Answers 100% Solved


A patient is experiencing oliguria. Which action should the nurse perform

first?

a. Increase the patient's intravenous fluid rate.

b. Encourage the patient to drink caffeinated beverages.

c. Assess for bladder distention.

d. Request an order for diuretics. - ✔✔C - Oliguria is urine output that is

decreased despite normal fluid intake. As a nurse we would assess for

bladder distention first because by gently palpating a patients bladder may

cause a patient the urge to urinate which may help us determine the urine

output.

A patient requests the nurse's assistance to the bedside commode and

becomes frustrated when unable to void in front of the nurse. The nurse

understands the patient's inability to void because:

a. Anxiety can make it difficult for abdominal and perineal muscles to relax

enough to void.

,©NINJANERD 2024/2025. YEAR PUBLISHED 2024.
b. The patient does not recognize the physiological signals that indicate a

need to void.

c. The patient is lonely, and calling the nurse in under false pretenses is a

way to get attention.

d. The patient is not drinking enough fluids to produce adequate urine

output. - ✔✔A - A nurse should understand the patients inability to void

because anxiety can cause urinary retention. When a patient normally

voids it involves contraction of the bladder and coordinated relaxation of the

urethral sphincter and pelvic floor; therefore, if a patient has anxiety toward

urinating in front of the nurse or others he/she may be tense and unable to

relax their muscles to urinate. Many patients may need privacy to help

prevent interruptions to allow them to relax.

An 86 year old patient tells the nurse that she is experiencing

uncontrollable leakage of urine. Which nursing diagnosis should the nurse

include in the patient's plan of care?

a. Urinary retention

b. Hesitancy

c. Urgency

d. Urinary Incontinence - ✔✔Urinary incontinence, which is the involuntary

leakage of urine that is sufficient to be a problem. Incontinence is more

, ©NINJANERD 2024/2025. YEAR PUBLISHED 2024.
common in older adults because the intra-abdominal pressure exceeds

urethral resistance, then the muscles around the urethra become weak.

Thus, allowing small amounts of urine to leak spontaneously.

The patient expresses difficulty voiding and the constant urge to urinate.

The nurse should follow up by:

a. Using a bladder scanner to determine if there is post-void residual.

b. Telling the patient to run water when voiding.

c. Instructing the patient to perform Kegel exercises.

d. Checking the patient's vital signs. - ✔✔A - The bladder scanner helps

assess for post-void residual (PVR). Residual urine or post-void residual

occurs if a patient has urinary retention or cannot empty the bladder

completely. This measurement would help the nurse see if the patient has

urine left in the bladder after voiding and/or if there is another issue with

voiding. A normal void the bladder should empty completely

A patient asks about treatment for urge incontinence. The nurse's best

response is to advise the patient to:

(Choose all that apply.)

a. perform pelvic floor exercises.

b. Bladder retraining

c. avoid voiding frequently.

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