Brenau Urinary Patterns HESI Case Study

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1. Mr. Ellis states that prior to his stroke, he Nocturia 6. The nursing staff continues with the bladder- - clean and
would get up five or six times during the training program, but Mr. Ellis' incontinence dry penis
night to empty his bladder but that he was shows little improvement. Since the bladder -apply skin
able to control the urge long enough to training has not been successful, the nurse cream
make it to the bathroom. How should the obtains a prescription to apply a condom -wrap
nurse describe the urinary pattern that Mr. catheter. Mr. Ellis is able to ambulate with adhesive
Ellis is describing? assistance.In what order should the spiral
prescribed condom catheter be applied to -place the
2. Since Mr. Ellis now voids spontaneously Incontinence
Mr. Ellis? (Arrange the options in the order rolled
without recognizing the need to void, how
they should be performed with the first condom
should the nurse document his current
action on top and the last action on the -attach a
urinary pattern in the medical chart?
bottom.) large leg
3. To help manage Mr. Ellis' incontinence, the Remind the drainage
nurse initiates a bladder training program. client to bag
Which instruction should the nurse provide to void every 2
7. Mr. Ellis is admitted to the acute care facility Wash
the unlicensed assistive personnel (UAP) who hours while
for minor surgery. His preoperative perineal
will be helping care for Mr. Ellis? awake and
prescriptions include the insertion of an area with
to call for
indwelling urinary catheter. A student nurse soap and
assistance to
is assigned to care for Mr. Ellis. The nursing water.
the
instructor asks the student nurse to prepare
bathroom.
to insert the indwelling catheter under
4. After several weeks, the bladder training - Risk for supervision.What is the first step in the
program is unsuccessful in stopping Mr. Ellis' impaired skin proper placement of an indwelling urinary
incontinence. Mr. Ellis appears withdrawn integrity catheter for a male client?
and states that he is frustrated at the number related to
8. The nurse reviews factors that may impact Prostate
of episodes that he is having.Which nursing urinary
catheter insertion with the student nurse. gland
diagnoses are appropriate for Mr. Ellis? incontinence.
Which physiologic change that commonly enlargement.
- Ineffective
occurs in elderly males may affect insertion
coping
of the catheter?
related to
inability to 9. The student obtains a 16 French Foley Deflate the
control urine catheter from the supply room. The student balloon and
leakage. nurse explains the procedure to Mr. Ellis, who insert the
gives permission to begin. After cleansing catheter
5. Following an episode of incontinence, the "Washing the
the urinary meatus, the student nurse farther.
nurse washes the client's perineal area with area with
maintains sterile technique while inserting
mild soap and water and applies a water- mild soap
the catheter into the urethra about 4 inches.
repellent ointment to the skin. Mr. Ellis' wife and water
While inflating the balloon, Mr. Ellis cries out
is present and the nurse uses this followed by
in obvious pain.What action should the
opportunity to educate her about proper skin ointment can
student nurse take?
care to prevent breakdown.Which of the help to
following statements made by Mrs. Ellis protect my 10. The catheter is successfully placed in the 16 French
indicates that teaching has been effective? husband's bladder with a return of 200 mL of clear, Foley
skin." yellow urine. The catheter is secured and Mr. catheter
Ellis is resting comfortably. In documenting inserted with
the catheter insertion procedure, which return of
statement should be included? clear,
yellow
urine.
11. Fill in the blank 650 16. Fill in the blank 180
Mr. Ellis returns from the Post Anesthesia Care The student nurse instills a total of 60 mL of
Unit (PACU) after his surgical procedure. He the correct solution and withdraws 40 mL of
has an IV of LR infusing at 125 mL/hr, O2 at 2 fluid containing several small blood clots. The
L/min per nasal cannula, and an indwelling student nurse then empties 200 mL from the
catheter attached to a drainage bag. Four urinary drainage bag.What urinary output
hours later, the nurse documents Mr. Ellis' should be recorded? (Enter the numerical
intake/output. The LR solution has been value only. If rounding is required, round to
running for 4 hours, and the nurse administers the whole number.)
and IV antibiotic that runs in 150 mL of normal
17. During the catheter irrigation, the nurse The client
saline. Mr. Ellis is still NPO after the
observes that Mr. Ellis is still confused and is at risk
procedure.How does the nurse document Mr.
attempts to pull at his urinary catheter, his IV, for self-
Ellis' intake in mL? (Enter numerical value
and his nasal cannula. The nurse considers the injury.
only. If rounding is necessary, round to the
use of wrist restraints on the basis of which
whole number?)
rationale?
12. Mr. Ellis is responsive but confused and Client is
18. The nurse notifies the HCP and obtains a Skin
frequently pulls on the urinary catheter. The confused
prescription for wrist restraints. The nurse integrity
nurse observes obvious hematuria in the and pulls
applies the restraints and plans to monitor the and pulse
drainage bag and notes the presence of on the
client every 30 minutes. Which assessments volume of
several blood clots in the tubing.How should Foley
are most important for the nurse to perform the
the nurse document this situation? catheter.
at each of these times? restrained
Urine is
extremities.
pinkish-red
Pulse rate
with blood
and
clots.
volume in
13. Mr. Ellis' hematuria continues. Two hours later, Evaluate the wrists.
he becomes restless and appears to be in the urinary
19. Mr. Ellis' confusion decreases, and 12 hours Obtain a
pain. The nurse observes that there has been drainage
later the nurse is able to remove the wrist sterile
no urinary output during the last 2 hours. tubing.
restraints. By the third postoperative day, no urine
Which assessment should the nurse complete
further hematuria or blood clots are observed specimen.
first?
in Mr. Ellis' urine. However, the nurse does
14. The nurse is unable to resolve the catheter Normal observe that the urine has developed a
obstruction using noninvasive measures and saline. cloudy appearance. Which action should the
notifies the healthcare provider (HCP), who nurse implement?
prescribes bladder irrigation to dislodge any
20. Urinalysis results are as follows:pH: Provide a
blood clots obstructing the urine flow.The
8.5Specific gravity: 1.015 Protein: none glass of
nurse anticipates that the prescription will
Glucose: none WBCs: 8 RBCs: 2 Bacteria: cranberry
include the use of which sterile solution to
presentBased on the urinalysis results, the juice daily.
irrigate the catheter?
HCP prescribes a broad-spectrum antibiotic.
15. The RN encourages the student nurse to Encourage After 24 hours of receiving the antibiotic, Mr.
perform the irrigation. The student prepares the student Ellis' condition has not improved. What
the solution, applies gloves, clamps the distal nurse to additional nursing intervention should the
tubing, and begins to clean the specimen port continue, nurse implement?
on the drainage tubing.What action should the maintaining
21. Which diagnostic test result would make the Urine
nurse take? aseptic
nurse concerned that the client is at risk for culture
technique.
sepsis? shows
resistance
to the
prescribed
antibiotic.
22. After reviewing Mr. Ellis' diagnostic test Drug 28. Mr. Ellis' incontinence continues. Use of the Acknowledge
results, the nurse consults with the HCP and toxicity condom catheter is resumed until Mr. Ellis to Mr. Ellis
receives a prescription for a new antibiotic. due to develops localized dermatitis. The condom the distress
Since Mr. Ellis' creatinine level is elevated, the reduced catheter is removed temporarily to that he is
nurse is concerned about which problem in drug promote healing, and although the nursing experiencing.
administering the medication? excretion. staff takes Mr. Ellis to the bathroom every 2
hours, he occasionally wets his clothing. The
23. The nurse notes that the medication dosage is Half-life.
nurse enters Mr. Ellis' room and finds him
in the safe range for elderly clients, which is
crying.What is the best initial response by
to be administered by IV every 12 hours. The
the nurse to this behavior?
nurse recognizes that the frequency of drug
administration is based on which characteristic 29. When Mr. Ellis is calm, the nurse assigns the Mr. Ellis'
of the medication? UAP to help him into dry clothing. Several room door is
minutes later, the nurse walks down the hall open to the
24. Fill in the blank 8
and sees the UAP in the room changing Mr. hallway.
Mr. Ellis' indwelling catheter is removed by
Ellis' clothes. The nurse enters the room
the nurse on the morning of Mr. Ellis'
and assesses the situation.Which aspect of
anticipated discharge. The nurse instructs the
the situation requires the nurse's most
UAP to report if Mr. Ellis has not voided within
immediate intervention?
how many hours? (Enter numerical value only.
If rounding is necessary, round to the whole
number.)
25. To encourage voiding, the RN instructs the Turn on
UAP to perform what intervention? the tap so
water is
running
when the
client
attempts
to void.
26. Mr. Ellis voids after the catheter is removed Is the
and he is discharged from the acute care medication
facility and transferred to the long-term care in
facility. Since he no longer has an IV, the extended-
prescription for his antibiotic is changed to an release
oral medication. Mr. Ellis has some difficulty form?
swallowing (dysphagia), and the nurse is
considering the best technique to help Mr.
Ellis swallow the medication.Before deciding
to open the capsule and mix it with food, what
will the nurse need to determine?
27. The nurse consults with the pharmacist, who Open the
determines that the capsule can be opened capsule
and mixed with a food that the client likes. and mix
Which technique should the nurse use? the
medication
with
pudding.