Ignatavicius & Workman: Medical-Surgical Nursing: Critical Thinking for
Collaborative Care, 5th Edition
Answer Guidelines – Study Guide Case Studies
Chapter 72: Assessment of the Renal/Urinary System
Case Study: Assessment of the Renal/Urinary System
A 74-year-old man is scheduled to have a series of urologic studies for diagnostic purposes. The
physician orders the following: urinalysis, urine for culture and sensitivity, BUN, serum creatine,
and 24-hour urine for creatinine clearance. The tests will be conducted on an outpatient basis.
1. Describe what the nurse should do to instruct the client in the collection of these laboratory
specimens.
See Table 72-5, “Collection of Urine Specimens.”
Voided urine: Collect the first specimen voided in the morning. Send the specimen to
the laboratory as soon as possible. Refrigerate the specimen if a delay is unavoidable.
Clean-catch specimen for culture and sensitivity: Explain the purpose of the procedure
to the client. Instruct the client to self-clean before voiding. Instruct the female client to separate
the labia and use the sponges and solution provided to wipe with three strokes over the urethra.
The first two wiping strokes are over each side of the urethra; the third wiping stroke is centered
over the urethra from front to back. Instruct the male client to retract the foreskin of the penis
and to similarly clean the urethra, using three wiping strokes with the sponge and solution
provided (from the head of the penis downward). Instruct the client to initiate voiding after
cleaning. The client then stops and resumes voiding into the container. Only 1 ounce (30 mL) is
needed; the remainder of the urine may be discarded into the commode. Ensure that the client
understands the procedure. Assist the client as needed.
24-Hour urine collection for creatinine clearance: Instruct the client thoroughly.
Provide written materials to assist in instruction. Place signs appropriately. Inform all personnel
or family caregivers of test in progress. Check laboratory or procedure manual on proper
technique for maintaining the collection (e.g., on ice, in a refrigerator, or with a preservative). On
initiation of the collection, ask the client to void, discard the urine, and note the time. If a Foley
catheter is in use, empty the tubing and drainage bag at the start time and discard the urine.
Collect all urine of the next 24 hours. Twenty-four hours after initiation, ask the client to empty
the bladder and add that urine to the container. Do not remove urine from the collection
container for other specimens.
The BUN and serum creatinine will be collected through blood samples taken by a
phlebotomist.
2. Which specimens should be collected first?
The urinalysis should be collected first, so it is a concentrated specimen. The clean-catch
specimen should be collected next, and the 24-hour collection started after the other two have
Copyright © 2006, 2002 by Elsevier Inc.
Answer Guidelines – Study Guide Case Studies
2
been collected and sent to the laboratory.
3. The client returns the collection container with a 24-hour urine specimen to the physician’s
office. As he gives it to the nurse, he comments, "I had a hard time remembering to save it
all. Actually, I think I missed some when I forgot and used a bathroom at the shopping mall
yesterday." What should the nurse do?
For a composite urine specimen, all urine within the designated time frame must be collected.
The nurse should instruct the client to repeat the collection and save all of his urine to the
sample.
4. Further tests are ordered for the client, including a renal ultrasound and intravenous
pyelography (IVP). These are scheduled at an outpatient radiology clinic. Design a teachinglearning plan for the client to prepare him for these studies.
See discussion beginning on textbook p. 1668.
For the ultrasound: Explain the rationale for the procedure and share information about
sensations commonly experienced during the procedure. For example, “This test will
measure the amount of urine in your bladder. I will place a gel pad just above your pubic area,
then place the probe that is a little bigger and heavier than a stethoscope on the gel.”
For the IVP: Instruct the client about bowel preparation. Assess for allergy information
and report to physician; instruct client that drugs such as steroids or antihistamines may be given
before the procedure if there is a chance of allergic reaction. Explain the rationale for the
procedure to the client. Instruct the client that he may be NPO after a light liquid supper before
the procedure or he may be encouraged to take fluids freely, depending on the physician’s order.
5. Following the ultrasound and IVP, what assessments should be made for the client?
Because there is no discomfort or risk involved with the ultrasound, no special follow-up care is
indicated. Following the IVP, monitor the client for altered renal function and other effects of
the dye. Ensure adequate hydration by urging the client to take oral fluid or by giving IV fluids.
Hydration reduces the risk for renal damage. Monitor blood creatinine levels to assess ongoing
renal function.
Copyright © 2006, 2002 by Elsevier Inc.