URINARY SYSTEM

NCM501 205 SY – 2011-2012

JARENDYKRICHE GROUP

On completion of this chapter, the learner will be able to:

1. Describe the anatomy and physiology of the upper and lower

urinary tracts.

2. Identify the assessment parameters used for determining the status

of upper and lower urinary tract function.

3. Describe the diagnostic studies used to determine upper and lower

urinary tract function.

4. Initiate education and preparation for patients undergoing assessment

of the urinary system.

5. Discuss the role of the kidney in regulating fluid and electrolyte

balance, acid–base balance, and blood pressure.

Learning Objective

Proper function of the urinary system is essential to life.

Dysfunction of the kidneys and lower urinary tract is common and may occur at any age and with varying levels of severity. Assessment of upper and lower urinary tract function is part of every health examination and necessitates an understanding of the anatomy and physiology of the urinary system as well as of the effect of changes in the system on other physiologic functions. The major role of the urinary system is to maintain homeostasis by maintaining body fluid composition and volume.

Urinary System

The urinary system comprises the kidneys, ureters, bladder, and

urethra. A thorough understanding of the urinary system is necessary

for assessing individuals with acute or chronic urinary dysfunction

and implementing appropriate nursing care.

ANATOMY OF THE UPPER

AND LOWER URINARY TRACTS

The urinary system—the structures of which precisely maintain

the internal chemical environment of the body—perform various

excretory, regulatory, and secretory functions.

Anatomic and Physiologic Overview

The kidneys are two bean-shaped organs located retro- peritoneally at the level of the twelfth thoracic and third lumbar vertebra (costovertebral angle).

The right kidney is slightly lower than the left kidney due to the presence of the liver on the right side of the abdomen.

The kidneys are divided into renal cortex, medulla and pelvis. The medulla is composed of series of pyramids.

The functional units of the kidneys are the nephrons. The nephron is composed of glumerulus and the renal tubules.

The glumerulus is a tuft of semi-permeable capillaries, surrounded by the Bowman’s capsule.

The three regions of the renal tubules are as follows: proximal convoluted tubules, loop of Henle and the distal convoluted tubules.

The Kidneys

The primary function of the nephron is formation of urine. About 1,200 mls of blood flows to the kidneys per minute,

which is 20 to 25% of the cardiac output. Through the formation of urine, the kidneys remove waste

products from the body, regulate fluid volume, maintain electrolyte concentration, blood pressure, and pH within the body.

The glomerular filtration rate (GFR) is 125 ml/min. From this, the kidneys form 0.5 to 1 ml of per minute, or 30 to 60 mls per hour, or approximately 1,500 mls per day of urine.

The Kidneys

• Figure 1

• Figure 2

• Figure 3

• Figure 4

• Figure 5

The ureters are two small tubes about 25 cm long. They transport urine from the renal pelvis to the urinary bladder.

The ureters enter the urinary bladder obliquely and are guarded by urterovesicular spinchter. These two factors prevent reflux of urine as the bladder contracts.

Ureters

Urinary bladder is a hollow, muscular organ that serves as a reservoir for urine and as the organ of excretion.

In men, the bladder lies in front of the rectum and above the prostate gland

In women it lies in front of the uterus and vagina. The wall of the bladder is made up of four layers (a) an inner

mucous layer , (b) a connective tissue layer, (c) three layers of smooth muscle fibers, (d) an outer serous layer. The smooth muscle layers are collectively called the detrusor muscle . The detrusor muscle allows the bladder to expand as it fills with urine, and to contract to release urine to the outside of the body during voiding.

Normal bladder capacity is between 300 and 600 ml of urine.

The Urinary Bladder

• Figure 6

The urethra extends from the bladder to the urinary meatus In the adult women, the urethra lies directly behind the

symphysis pubis, anterior to the vagina, and is between 3 and 4cm long. The urethra serves only as a passage way for the elimination of urine.

In the male, the urethra is approximately 20 cm long and serves as a passageway for semen as well as urine.

In both men and women, the urethra has a mucous membrane lining that is continuous with the bladder and the ureters. Thus an infection of the urethra can extend through the urinary tract to the kidneys.

The Urethra

• Figure 7

The vagina and the urethra and rectum pass through the pelvic floor which consists of sheets of muscles and ligaments that provide support to the viscera of the pelvis.

The internal sphincter muscle situated in the proximal urethra and the bladder neck is composed of smooth muscle under involuntary control.

The external sphincter muscle is composed of skeletal muscle under voluntary control, allowing the individual to choose when urine is eliminated.

The Pelvic Floor

Figure 8

The three steps of formation of urine by the kidneys are as follows:

1. Glomerular Filtrationo Water and solutes move from the blood to the glomerular

capsule. The fluid that enters the capsule is called glomerular filtrate.

2. Tubular Reabsorptiono It is the movement of the substances from the filtrate in the

kidney tubules into the blood in the peritubular capilliaries. Only 1% of the filtrate remains in the tubules and become urine. Water and other substances that are useful to the are reabsorbed. Water is reabsorbed by osmosis, while most solutes are reabsorbed by active transport.

Urine Formation

3. Tubular Secretiono It is the transport of substances from the blood into the renal

tubules. Potassium and hydrogen are primarily eliminated from the body. Ammonia, uric acid, some drug metabolites are likewise eliminated.

.

Urine Formation

Micturition, voiding, urination all refer to the process of emptying the urinary bladder.

Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors. This occurs when the adult bladder contains between 250-500 ml of urine. Children bladder contains between 50-200 ml of urine, stimulates these nerves.

Stretch receptors transmit impulses to the spinal cord, voiding reflex center located at the level of the 2nd to 4th sacral vertebrae causing Internal sphincter to relax Stimulation to void. If the time and the place are appropriate for urination, conscious portion of the brain relaxes the external urethral sphincter muscle and urination takes place.

Urination

Facts About Urine

Facts about urine: Adults pass about a quart and a half of urine each

day, depending on the fluids and foods consumed. The volume of urine formed at night is about half that

formed in the daytime. Normal urine is sterile. It contains fluids, salts and

waste products, but it is free of bacteria, viruses and fungi.

The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall.

Video Clip

Factors affecting voiding

Developmental factors

Infants

During the first year, U.O gradually increases according to fluid intake to 250 – 500 ml / a day.

Infant may urinate as often as 20 times a day. Characteristic of urine, colorless, odorless, specific gravity of 1.008. Urine control between ages 2 and 5 years.

 

Urinary Elimination

The preschooler is able to take responsibility for independent toileting. Parent need to realize that accidents do occur and the child should never be punished.

 

School – age children

The kidneys double in size between ages 5 and 10 years. During this period the elimination system reaches maturity.

Preschoolers

Enuresis, Involuntary passing of urine when control should be established (about 5 years of ages). Nocturnal enuresis or bed wetting is involuntary passing of urine during sleep. Bed – wetting should not be considered a problem until after the age of 6.

The nocturnal enuresis can be divided into:

Primary enuresis :-

When the child has never achieved night time urinary control.

Secondary enuresis :-

Related to another physical problem and resolves when the cause is eliminated.

Causes: - stress, illness.

Urinary Elimination

o Excretory function of the kidney diminishes with age, but not less than normal unless a disease is occur.

o With age, the number of functioning nephrons decreases to some degree, impairing the kidney’s filtering abilities.

o Bladder muscle tone diminishes, causing increased frequency of urination and nocturia ( awakening to urinate at night).

o Diminished bladder muscle tone and contractibility may lead to residual urine in the bladder after voiding, increasing the risk of bacterial growth and infection.

Elders

A set of conditions helps stimulate the micturition reflex , include privacy , normal position , sufficient time , running water sometimes the client’s accustomed conditions may produce anxiety and muscle tension , also some people may voluntarily suppress urination because of time pressure , for example nurses often ignore the urge to void until they are able to take a break.

Psychological factors

The healthy body maintains a balance between the amount of fluid ingested and the amount of fluid eliminated if fluid intake ↑, the output ↑.

Certain fluids, e.g alcohol, ↑ fluid output by inhibiting ADH production.

Fluid that contain caffeine (e.g coffee, tea, cola) ↑ urine production.

Foods and fluids high in sodium can cause fluid retention. Some foods and fluids can change the color of urine. Beets can cause urine to appear red.

Carotene can cause the urine to appear yellow than food containing usual.

Fluid and food intake

Many medications affecting the autonomic nervous system interfere with the normal urination process and may cause retention. Diuretics (e.g chlorothiazide, furosemide) ↑ urine formation by preventing the reabsorption of water and electrolytes from the tubules of the kidney into blood stream.

Muscle tone Good muscle tone is important to maintain the stretch and

contractility of the detrusor muscle so the bladder can fill adequately and empty completely.

Medications

Diseases of the kidneys may affect the ability of the nephrons to produce urine .

Heart and circulatory disorders such as heart failure, shock hypertension can affect blood flow to the kidneys, interfering with urine production.

Abnormal amounts of fluid loss (vomiting or high fever). Water is retained by the kidneys and urinary output falls.

A urinary stone may obstruct a ureters , blocking urine flow from the kidney to the bladder.

Hyper trophy of the prostate gland may obstruct the urethra impairing urination and bladder emptying

Pathologic conditions

May affect the passage of urine and the urine itself Cystoscopy, surgical procedures, spinal anesthetics.

Altered urine production

Polyuria ( diuresis )

Production of abnormally large amounts of urine by the kidneys,often several liters more than the client’s usual daily output.

Causes:-

Excessive fluid intake (polydipsia).

Associated with diabetes mellitus.

Diabetes insipidus.

Chronic nephritis.

 Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, Weight loss.

Surgical and diagnostic procedures

Oliguria and Anuria

Oliguria is low urine output, usually less than 500 ml a day or 30 ml an hour for an adult.

 Anuria refers to lack of urine production.

 Causes:-

Lack of fluid intake.

Impaired blood flow to the kidneys.

Renal failure.

Altered urinary elimination

 Frequency and Nocturia

Urinary frequency is voiding at frequent intervals, that is, more often than 4 to 6 times per day.

Causes:-

UTI.

Stress.

Pregnancy can cause frequent voiding of small quantities (50 to 100 ml) of urine.

 Nocturia is voiding two or more times at night.

Urgency

Is the sudden strong desire to void.

Causes:-

Psychological stress and irritation of the trigone and urethra.

Common in young children who have poor external sphincter control and unstable bladder contractions.

 

Dysuria

Voiding that is either painful or difficult.

Causes

UTI.

Injury to the bladder and urethra.

Often Urinary hesitancy (a delay and difficulty in initiating voiding) is associated with dysuria.

Enuresis

Involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4 or 5 years of age .Nocturnal enuresis often is irregular in occurrence and affects boys more often than girls. Diurnal (day time) enuresis may be persistent and pathologic in origin .It affects women and girls.

Urinary incontinence Or involuntary urination is a symptom not a disease. Clients at highest risk for developing incontinence include

those with:- A history of UTI. Surgery. Trauma. STD. Multiply vaginal births. Musculoskeletal. Endocrine. Neurological disorders

Urinary retention

Is impaired in the emptying of the bladder, urine accumulates and the bladder becomes over distended.

Causes :

Prostatic hypertrophy (enlargement).

Surgery.

Some medication.

The client may experience over flow voiding or incontinence eliminating 25 to 50 ml of urine at frequent intervals.

Neurogenic bladder

Impaired neurologic function can interfere with the normal mechanism of urine elimination .The client with a neurogenic bladder does not perceive bladder fullness and is unable to control the urinary sphincters. The bladder may become flaccid and distended or spastic with frequent involuntary urination.

Nursing management

Assessing Nursing history. Physical assessment

- Percussion of the kidneys to detect areas of tenderness

- Palpation and percussion of the bladder.

- Inspection of the urethral meatus of both male and female for swelling, discharge, and inflammation.

Assessing urine

- Normal urine consists of 96% water and 4% solutes. Organic solutes include urea, ammonia, creatinine and uric acid. Inorganic solutes include sodium chloride, potassium sulfate, magnesium and phosphorus.

Measuring urinary output

Normally the kidneys produce urine at a rate of approximately 60 ml per hour or about 1500ml/day.

Measuring residual urine

Residual urine (urine remaining in the bladder following the voiding) is normally 50 to 100 ml.

Diagnostic tests • Blood tests [urea, creatinine] used to evaluate renal function.

Urea, end product of protein metabolism is measured as BUN.• Creatinine is product in relatively constant quantities by the

muscles.

Creatinine clearance test

- Uses 24 hour urine and serum creatinine levels to determine the glomerular filtration rate, a sensitive indicator of renal function.

Diagnosing

NANDA includes one general diagnostic label for urinary elimination problems and several labels that are more specific.

- Impaired urinary elimination

ALSO FROM PAGE 1296

- Risk for infection

Etiology:-

Urinary retention

Invasive procedure (catheterization or Cystoscopy)

- Low self – esteem or social isolation

Etiology:-

Urinary incontinence

Risk for impaired skin integrity

Etiology:-

Urinary incontinence

- Risk for social isolation: if the client is incontinent.- Disturbed body image: if the client has a urinary diversion

ostomy

Implementing

Maintaining normal urinary elimination which include

Promoting adequate fluid intake by: ↑ fluid intake → ↑urine production A normal daily intake 1500ml fluids Client who are risk for UTI, urinary calculi ( stones) should

consume 2000 to 3000ml of fluids daily .

Maintaining normal voiding habits

Assisting with toileting Assist the clients to the bathroom and remain with them if

they are risk for falling Provides urinary equipment (urinal, bedpan, and commode).

Preventing urinary tract infections.

Rate of UTI in women is about 20% in men 0.1%. Most common causes of UTI is bacteria

(E. coli).

Instructions provided for the client to reduce the occurrence of UTI:-

Drink 8 glasses of water/ day.

Practice frequent voiding every (2 to 4 hours).

Void immediately after intercourse.

Avoid use of harsh soaps, bubble bath, and powder.

Avoid tight – fitting pants.

Wear cotton rather than nylon under clothes.

Girls and women should always wipe the perineal area from front to back.

↑ The acidity of urine through regular intake of vitamin C .

Managing Urinary Incontinence

Continence (Bladder) Training

A bladder training program may include the following:• The client post pone voiding• Resist or inhibit the sensation of urgency• Void according to a time table rather than according to the

urge to void• voiding may be encouraged every 2 to 3 hours except during

sleep and then every 4 to 6 hours• Practice deep, slow breathing until the urge diminishes or

disappears this inhibiting the urge to void sensation.

Pelvic muscle exercises (PME) or Kegel exercises help to:-

Strengthen pelvic floor muscles and can reduce or eliminate episodes of incontinence.

The client can identify the perineal muscles by stopping urination mid stream or by tightening the anal sphincter.

Urinary Catheterization

Urinary catheterization is the introduction of a catheter through the urethra into the bladder for the purpose of withdrawing urine.

Catheter; is the tube for injecting or removing fluids

Catheterization considered the most common cause of nosocomial infections that is infection acquired in hospital

Types of catheters

Retention catheter or Foley catheter; is a catheter that remain in place for continuous drainage

Straight catheter or intermittent are used to drain the bladder for shorter periods from 5-10 minutes patients can be taught for straight catheter

Supra-pubic catheter; used for continuous drainage this type of catheter is surgically inserted through a small incision above the pubic area

Reasons for catheterization:• To relieve urinary retention• To obtain a sterile urine specimen especially in women• To measure the amount of urine• To empty the bladder during or after surgery and before

certain diagnostic examination

Hazards of catheterization:

1) Infection 2) Trauma 3) Sepsis

Nursing Intervention for clients with indwelling catheters

1. Fluid

The client with a retention catheter should drink up to 3,000 ml per day if permitted.

2. Dietary measures

Acidifying the urine of clients may reduce the risk of urinary tract infection and calculus formation. Foods such as eggs, cheese, meat, tomatoes tend to increase the acidity of the urine. Unlike the fruits and vegetables, milk and milk products result in alkaline urine

3. Perineal care

4. Changing the catheter and tubing

Urinary irrigations

Is a flushing or washing out with a specified solution usually to wash out the bladder and some times to apply a medication to the bladder lining. The closed method of catheter or bladder irrigation a three- way, or triple lumen catheter used for closed irrigations. Open method of catheter irrigations performed with double- lumen indwelling catheters.

Urinary diversions

Is the surgical rerouting of urine from the kidneys to a site other than the bladder. Urinary diversion created when the bladder must be removed for example cancer, trauma.

There are types of diversions

1. Incontinent

Clients have no control over the passage of urine and require the use of an external ostomy appliance to contain the urine

Examples of incontinent diversions include:- Ureterostomy

Is when one or both of the ureters may be brought directly to the side of the abdomen to form small stomas.

Nephrostomy

Diverts urine from the kidney to a stoma

Vesicostomy

Bladder is left intact but voiding through the urethra is not possible (e.g. obstruction, neurogenic bladder). The ureters remain connected to the bladder, and the bladder wall is sutured to the abdominal wall, forming an incontinent stoma.

ileal conduit ( ileal loop )

A segment of the ileum is removed and the intestinal ends are reattached. One end of the portion removed is closed with sutures to create a pouch, and the other end is brought out through the abdominal wall to create a stoma. The ureters are implanted into the ileal pouch

. Continent

This mechanism giving clients control over the passage of urine.

Examples of continent diversions include:-

Kock pouch or continent ileal bladder conduit

Neobladder

The nurse is aware that the following findings would be further evidence of a urethral injury in a male client during rectal examination?a. A low-riding prostateb. The presence of a boggy massc. Absent sphincter toned. A positive Hemoccult

2. When a female client with an indwelling urinary (Foley) catheter insists on walking to the hospital lobby to visit with family members, nurse Rose teaches how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information?a. The client sets the drainage bag on the floor while sitting down.b. The client keeps the drainage bag below the bladder at all times.c. The client clamps the catheter drainage tubing while visiting with the family.d. The client loops the drainage tubing below its point of entry into the drainage bag.

3. A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?a. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.b. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.c. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse.d. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.

4. A male client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client’s pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should nurse Katrina conclude?a. The skin wasn’t lubricated before the pouch was applied.b. The pouch faceplate doesn’t fit the stoma.c. A skin barrier was applied properly.d. Stoma dilation wasn’t performed.

5. The nurse is aware that the following laboratory values supports a diagnosis of pyelonephritis?a. Myoglobinuriab. Ketonuriac. Pyuriad. Low white blood cell (WBC) count

Critical Thinking

6. A female client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, nurse Sarah knows that the client is most likely to experience:a. hematuria.b. weight loss.c. increased urine output.d. increased blood pressure.

7. Nurse Lea is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention?a. Rashes on the palms of the hands and soles of the feetb. Cauliflower-like warts on the penisc. Painful red papules on the shaft of the penisd. Foul-smelling discharge from the penis

8. Nurse Agnes is reviewing the report of a client’s routine urinalysis. Which value should the nurse consider abnormal?a. Specific gravity of 1.03b. Urine pH of 3.0c. Absence of proteind. Absence of glucose

9. A male client is scheduled for a renal clearance test. Nurse Maureen should explain that this test is done to assess the kidneys’ ability to remove a substance from the plasma in:a. 1 minute.b. 30 minutes.c. 1 hour.d. 24 hours.

10. A male client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should:a. keep the client’s knee on the affected side bent for 6 hours.b. apply pressure to the puncture site for 30 minutes.c. check the client’s pedal pulses frequently.d. remove the dressing on the puncture site after vital signs stabilize.

Critical Thinking

11. A female client is admitted for treatment of chronic renal failure (CRF). Nurse Juliet knows that this disorder increases the client’s risk of:a. water and sodium retention secondary to a severe decrease in the glomerular filtration rate.b. a decreased serum phosphate level secondary to kidney failure.c. an increased serum calcium level secondary to kidney failure.d. metabolic alkalosis secondary to retention of hydrogen ions.

12. Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a female client’s uremia. Which finding signals a significant problem during this procedure?a. Potassium level of 3.5 mEq/Lb. Hematocrit (HCT) of 35%c. Blood glucose level of 200 mg/dld. White blood cell (WBC) count of 20,000/mm3

13. For a male client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important?a. Encouraging coughing and deep breathingb. Promoting carbohydrate intakec. Limiting fluid intaked. Providing pain-relief measures

14. A female client requires hemodialysis. Which of the following drugs should be withheld before this procedure?a. Phosphate bindersb. Insulinc. Antibioticsd. Cardiac glycosides

15. A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), Dr. Smith orders diagnostic tests of the vaginal discharge. Which STD must be reported to the public health department?a. Chlamydiab. Gonorrheac. Genital herpesd. Human papillomavirus infection

Critical Thinking

16. A male client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the prescribed regimen?a. Urine output increases to 2,000 ml/day.b. Flank and abdominal discomfort decrease.c. Bacteria are absent on urine culture.d. The red blood cell (RBC) count is normal.

17. A 26-year-old female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She’s placed on trimethoprim-sulfamethoxazole (Bactrim) to treat possible infection. Another medication is prescribed to decrease the pain and frequency. Which of the following is the most likely medication prescribed?a. nitrofurantoin (Macrodantin)b. ibuprofen (Motrin)c. acetaminophen with codeined. phenazopyridine (Pyridium)

18. A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the nurse is aware that the functions of the three lumens include:a. Continuous inflow and outflow of irrigation solution.b. Intermittent inflow and continuous outflow of irrigation solution.c. Continuous inflow and intermittent outflow of irrigation solution.d. Intermittent flow of irrigation solution and prevention of hemorrhage.

19. Nurse Claudine is reviewing a client’s fluid intake and output record. Fluid intake and urine output should relate in which way?a. Fluid intake should be double the urine output.b. Fluid intake should be approximately equal to the urine output.c. Fluid intake should be half the urine output.d. Fluid intake should be inversely proportional to the urine output.

20. After trying to conceive for a year, a couple consults an infertility specialist. When obtaining a history from the husband, nurse Jenny inquires about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility?a. Chickenpoxb. Measlesc. Mumpsd. Scarlet fever

Critical Thinking

1. Answer B. When the urethra is ruptured, a hematoma or collection of blood separates the two sections of urethra. This may feel like a boggy mass on rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a nonurethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood would probably correlate with GI bleeding or a colon injury.

2. Answer B. To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn’t lay the drainage bag on the floor because it could become grossly contaminated. The client shouldn’t clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag.

3. Answer A. Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won’t protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx.

4. Answer B. If the pouch faceplate doesn’t fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldn’t be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isn’t performed with an ileal conduit, although it may be done with a colostomy if ordered.

5. Answer C. Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low, as indicated in option D. Ketonuria indicates a diabetic state.

Answers with Rationale

6. Answer B. Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn’t increase urine output because it doesn’t correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure.

7. Answer D. Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes.

8. Answer B. Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client’s value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, its color ranging from pale yellow to deep amber.

9. Answer A. The renal clearance test determines the kidneys’ ability to remove a substance from the plasma in 1 minute. It doesn’t measure the kidneys’ ability to remove a substance over a longer period.

10. Answer C. After renal angiography involving a femoral puncture site, the nurse should check the client’s pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client’s knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn’t remove this dressing for several hours — and only if instructed to do so.

Answers with Rationale

11. Answer A. A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys’ inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions.

12. Answer D. An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it’s readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn’t abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

13. Answer C. During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn’t take precedence over fluid limitation. Controlling pain isn’t important because ARF rarely causes pain.

14. Answer D. Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity. Phosphate binders and insulin can be administered because they aren’t removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis.

15. Answer B. Gonorrhea must be reported to the public health department. Chlamydia, genital herpes, and human papillomavirus infection aren’t reportable diseases.

Answers with Rationale

16. Answer C. Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect. Although flank pain may decrease as the infection resolves, this isn’t a reliable indicator of the drug’s effectiveness. Co-trimoxazole doesn’t affect urine output or the RBC count.

17. Answer D. Phenazopyridine may be prescribed in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on the urinary mucosa, phenazopyridine specifically relieves bladder pain. Nitrofurantoin is a urinary antiseptic with no analgesic properties. While ibuprofen and acetaminophen with codeine are analgesics, they don’t exert a direct effect on the urinary mucosa.

18. Answer A. When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.

19. Answer B. Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn’t inversely proportional to the urine output.

20. Answer C. Mumps is the most significant childhood infectious disease affecting male fertility. Chickenpox, measles, and scarlet fever don’t affect male fertility.

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