Urinary Elimination NCLEX Questions
Question 1 of 5.
The Somali parents bring their 1-year-old child to the ER of a large urban hospital. The child is lethargic and has bloody urine and blood seeping through a diaper. The child's parents do not speak English. Which intervention should the nurse implement first?
A. Check the child's BP.
B. Arrange for an interpreter.
C. Inspect the child's genitalia.
D. Obtain urine and blood cultures.
Explanation: The nurse should first request an interpreter because parental consent is needed for assessment and treatment of the child. Most major health care facilities usually have an on-site interpreter or have made arrangements for on-demand remote video or telephone interpreting services. The BP is important to assess perfusion, but the parents may not allow the child to be touched without first communicating through an interpreter. Although blood seeping through the diaper and the fact that the parents are Somali may lead the nurse to think about female genital mutilation, there is no information to substantiate this. The genitalia may need to be inspected, but parental consent is needed first. Blood and urine cultures may need to be obtained to determine if the child has a UTI or is septic or dehydrated, but an interpreter is needed first to explain the tests to the parents.
Question 2 of 5.
The nurse is preparing the adolescent female client for a renal/bladder ultrasound. Which explanation is most appropriate?
A. "Do not void before the procedure; a full bladder helps to identify important structures."Â
B. "Void immediately before the procedure; a full bladder impairs seeing important structures."Â
C. "You will be asked to void during the procedure in order to obtain the best results."Â
D. "A urinary catheter will be inserted to ensure that your bladder is empty during the test."Â
Explanation: A full bladder is important during a renal ultrasound to permit the best visualization of structures. Voiding before the procedure is not recommended. Voiding during the procedure is not recommended. A urinary catheter would not be inserted because it would empty the bladder and structures would not be visualized.
Question 3 of 5.
The nurse is taking a history of the 9-month-old. Which finding is most important for the nurse to report to the HCP for further follow-up?
A. Last diaper had urine that was odorless
B. Last diaper was stained with dark amber urine
C. Has not had a wet diaper in a 24-hour period
D. Usual urinary output about 250 mL per day
Explanation: Anuria, or a lack of urine production, may be a sign of altered renal function and is the most critical finding to report. Infants often have odorless urine, so this is not concerning. Dark amber urine may require more inquiry, although it is not the most important finding to report. Output for a 9-month-old is usually between 250 and 500 mL daily, so 250 mL is within normal range but on the lower end.
Question 4 of 5.
The nurse is caring for multiple clients preparing for placement of an external diversional urinary system. Which client has the greatest need for interventions to promote a positive body image?
A. An infant who has spina bifida
B. A toddler recently toilet trained
C. A school-aged child in foster care
D. An adolescent who is sexually active
Explanation: Because of the client's developmental stage and sexual activity status, an external urinary device places the adolescent at the greatest risk for body image disturbance, and thus the client has the greatest need for intervention. Developmentally, according to Havighurst, an adolescent's developmental task is to accept one's physique and use the body effectively; according to Erikson, the adolescent's task is to achieve a coherent sense of self. An infant is unaware of body alterations. A toddler could be at risk, depending on responses from others, but less so than an adolescent. A school-aged child may face body image issues if unable to develop competence with the device, but the adolescent's developmental stage makes them most vulnerable.
Question 5 of 5.
The nurse is educating the parent of the child with vesicoureteral reflux. The therapeutic use of which treatment is important to include in the teaching?
A. Steroidal therapy for at least 3 to 6 months
B. Acetaminophen three times daily for pelvic pain
C. Prophylactic antibiotics until the condition resolves
D. Growth hormone (GH) injections to prevent renal failure
Explanation: Vesicoureteral reflux is retrograde flow of urine from the bladder into the ureters from an incompetent valve that prevents backflow. Because urine is retained in the ureters after voiding, stasis of this urine leads to infection. Infection is managed with prophylactic antibiotic therapy until such an age as the condition resolves. Steroids are unnecessary, high doses of acetaminophen can lead to renal impairment, and GH injections are unrelated to vesicoureteral reflux.