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NUR 231 Exam 2 Questions And Answers
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NUR 231 Exam 2 Questions And AnswersThe client is exhibiting oliguria. Which is the nurse's first action?
a. Increase the intravenous fluid rate for the client.
b. Encourage the client to drink beverages containing caffeine.
c. Check the client for bladder distention.
d. Order diuretics. -ANSWER 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 that the nurse take them to the bedside commode and becomes
furious when they are unable to void in front of the nurse. The nurse can understand
why this patient is unable to void because: a. Anxiety makes it difficult for abdominal and
perineal muscles to relax sufficiently to urinate. b. The patient is unable to recognize
physiological clues that identify the 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. - ANSWER
A - A nurse should understand the patients inability to void because anxiety can cause
urinary retention. Normally, when a patient voids, it involves the contraction of the
bladder and the coordinated relaxation of the urethral sphincter and pelvic floor. Thus, if
a patient is anxious about urinating in front of the nurse or others, he/she may be tense
and not in a position to relax his/her muscles to urinate. Many patients may require
privacy to help prevent interruptions that allow them to relax.
An 86-year-old female patient informs the nurse that she is experiencing involuntary
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 - ANS The involuntary leakage of urine that is sufficient to
constitute a problem. Incontinence is more 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. Utilizing a bladder scanner to identify any post-void residual.
b. Having the patient run water while voiding.
c. Instructing the patient on Kegel exercises.
d. Check patient's vital signs. -ANWER 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 problem with voiding. A normal void should empty the bladder completely.
A patient asks about treatment for urge incontinence. The nurse's best response is to
advise the patient to:
(Select all that apply.)
a. exercise pelvic floor muscles.
b. Bladder retraining
c. avoid frequent voiding.
d. Wear absorbent products. - ANSWER A, B, D - Strengthen pelvic floor muscles and
consist of repetitive contractions of muscle groups. The exercises are noninvasive and
carry a low risk of adverse effects. In bladder training, the aim is to decrease the
frequency of voiding and thereby maybe the capacity of the bladder. The retraining can
hopefully reinstate a normal pattern of voiding by teaching patients to keep the patient
continent.Wearing absorbent pads promotes comfort for the patient. Comfort is derived
by an incontinent patient from having clean and dry clothing.
To obtain a clean-catch voided urine specimen from a female patient, the nurse should
instruct the patient to:
(Select all that apply.)
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