The Nurse’s Role in Urinary Elimination

Every question here, with the answer

1. A postoperative patient reports lower abdominal discomfort and has been unable to void. Which nursing action best evaluates whether urine is being retained in the bladder?

   1. Use a bladder scanner to measure the amount of urine present.
   2. Ask the patient whether the urine has a foul odor.
   3. Document the finding as expected and reassess at the end of the shift.
   4. Send a urine specimen only to evaluate pH.

   Answer: Use a bladder scanner to measure the amount of urine present.

   A bladder scan is a noninvasive way to assess urine volume in the bladder and helps identify urinary retention. Urine pH or odor may provide other information but does not measure retained urine, and delaying assessment could miss retention and its complications.

2. A nurse is assessing a patient for possible urinary retention. Which assessment findings or actions are appropriate? Select all that apply.

   1. Ask whether the patient strains during voiding.
   2. Inspect the patient’s urine only for pale yellow color.
   3. Percuss the lower abdomen to assess for dullness.
   4. Palpate the lower abdomen for a distended bladder.
   5. Ask about the frequency and volume of urination.

   Answer: Ask whether the patient strains during voiding., Percuss the lower abdomen to assess for dullness., Palpate the lower abdomen for a distended bladder., Ask about the frequency and volume of urination.

   Assessment for urinary retention includes questions about voiding patterns, straining, and discomfort, as well as physical assessment for a distended bladder. Urine color can be useful in urinalysis but does not directly assess bladder retention.

3. A nurse reviews a patient’s intake and output record and notes a urine output of 400 mL in 24 hours. How should the nurse interpret this finding?

   1. Oliguria
   2. Anuria
   3. Polyuria
   4. Normal urine output

   Answer: Oliguria

   A 24-hour urine output of 400 mL falls within the oliguria range. It is not normal output, not polyuria, and not anuria because anuria is a much lower volume.

4. A patient tells the nurse, “I leak urine when I laugh or cough, but I’m embarrassed to talk about it. Maybe it is just part of aging.” Which nursing response is most appropriate?

   1. “Thank you for telling me. Let’s discuss when it started and what triggers it so we can look at ways to manage it.”
   2. “You should avoid social activities until the leaking stops.”
   3. “You are right; this is a normal part of aging and usually does not need discussion.”
   4. “There is no need to assess this unless you also have pain with urination.”

   Answer: “Thank you for telling me. Let’s discuss when it started and what triggers it so we can look at ways to manage it.”

   The nurse should address urinary incontinence sensitively, assess patterns and triggers, and provide education about prevention or management. The section notes that some patients mistakenly believe incontinence is a normal part of aging, and embarrassment can lead to isolation.