Medical Surgical Chapter 58 URinary

The hemodialysis client is scheduled to receive weekly injections of epoetin (Epogen). Which is the most important consideration to be taken by the nurse in the administration of this medication? A) Schedule injection on nondialysis day. B) Administer immediately after dialysis. C) Monitor complete blood count prior to dose. D) Administer with low-dose aspirin to prevent clot formation.

Ans: A Feedback: After dialysis, do not administer injections for 2 to 4 hours to allow time for the metabolism and excretion of heparin (which is administered during dialysis). Serum laboratory tests are performed on a routine basis to identify normal and abnormal findings. Aspirin use is not indicated with Epogen use.

A client with chronic glomerulonephritis has generalized edema. Which response by the nurse best describes why anasarca occurs with this disorder? A) Fluid shifting occurs due to loss of serum protein. B) Albumin levels increase in the blood dragging fluid inside the vessels. C) Increased intake of sodium in the diet results in anasarca. D) Urinary retention promotes the absorption of fluid into tissue spaces.

Ans: A Feedback: Anasarca is caused by the shift of fluid from the intravascular space to interstitial and intracellular locations. The fluid shift results from depletion of protein from the blood (serum) to the urine. Sodium intake should be limited in clients with renal disease. Urinary retention is not indicated with anasarca.

A client, who has suffered with recurrent renal calculi, has learned that the stones were composed of calcium oxalate. In providing dietary education to this client, which food contains the highest levels of oxalate and should be limited? A) Bananas B) Chocolate C) Herbal teas D) Beef

Ans: B Feedback: Because as many as 80% of all renal calculi are composed of calcium oxalate, some believe limiting the amount of oxalate taken in via diet can be helpful. Milk, chocolate, and cocoa are highest in oxalate. Black tea is also high in oxalate. Bananas, herbal tea, and beef are not indicated as high oxalate foods.

A 176-lb client with pyelonephritis has been instructed to drink at least 30 mL of water for each kilogram of body weight. The client prefers to drink bottled water and asks the nurse to calculate the number of 16-oz bottles needed to fulfill the daily intake required. Fill in the blank with the total number of 16-oz bottles of water that should be consumed each day. __________ bottles

Ans: 5 bottles Feedback: Step 1. 2.2 lb : 1 kg :: 176 lb: X kg 176 = 2.2 X 80 kg = X Step 2. Multiply 80 kg by 30 mL = 2400 mL/day Step 3. 30 mL : 1 oz :: 2400 mL : X oz 2400 = 30 X 80 oz = X Step 4.16 oz : 1 bottle :: 80 oz : X bottles 80 = 16 X 5 bottles = X

Following ureteroscopy, for the removal of ureteral calculus, a stent is temporarily left in place. The client asks what purpose the stent provides. Which is the best response from the nurse? A) "The stent is coated with an antiinfective to promote healing." B) "The stent will catch any debris or blood clots left behind." C) "The stent will provide easier passing of future stones." D) "Inflammation from the stone can block the flow of urine."

Ans: D Feedback: Calculi can traumatize the lining of the ureters, resulting in inflammation and possible obstruction of urine flow. A stent is left behind to allow free-flowing urine until inflammatory process has resolved. Stent are not used for anti-infective properties or to catch debris or clots. Stents are not permanently placed for preventative measures.

As the home health nurse reviews medications taken by the client with polycystic kidney disease, which medication should be addressed first? A) Lovastin (Mevacor) B) Methylprednisolone (Depo-Medrol) C) Furosemide (Lasix) D) Ibuprofen (Motrin)

Ans: D Feedback: Nephrotoxic drugs are not administered to clients with renal disease unless no other therapeutic agent is available. Ibuprofen (Motrin) is a nephrotoxic drug and nephrotoxic medications, such as nonsteroidal anti-inflammatory drugs and cephalosporin antibiotics, should be avoided in treating clients with polycystic kidney disease. Lovastin (Mevacor) (antihyperlidemic agent) and methylprednisolone (Depo-Medrol) (steroid) are drugs presently being reviewed for slowing the rate of disease progression in clients with polycystic kidney disease and are not considered nephrotoxic. Furosemide (Lasix) is a diuretic and has no significance in causing renal damage.

The nurse performs a physical examination on a client diagnosed with acute pyelonephritis to assist in determining which of the following? A) Abnormalities in urine B) Location of discomfort C) Elevated calcium levels D) Structural defects in the kidneys

Ans: B Feedback: The physical examination of a client with pyelonephritis helps the nurse determine the location of discomfort and signs of fluid retention, such as peripheral edema or shortness of breath. Observing and documenting the characteristics of the client's urine helps the nurse detect abnormalities in the urine. Laboratory blood tests reveal elevated calcium levels, whereas radiography and ultrasonography depict structural defects in the kidneys.

A child is brought into the clinic with symptoms of periorbital edema and dark brown rusty urine. Which nursing assessment finding would best assist in determining the cause of this problem? A) Sore throat 2 weeks ago B) Red blood cells in the urine C) Elevation of blood pressure D) Protein elevation in the urine

Ans: A Feedback: Acute glomerulonephritis usually occurs as a result of bacterial infection such as seen with a beta-hemolytic streptococcal infection or impetigo. RBC and protein found in the urine and elevation of blood pressure are symptoms associated with glomerulonephritis.

The office nurse is providing information to a client who has experienced recurrent renal calculi. Which of the following jobs would place a client at greatest risk for calculi formation? A) Over-the-road truck driver B) Mining engineer C) Nursing instructor D) Rumba instructor

Ans: A Feedback: Calculi formation is often associated with immobility and/or stasis of urine. Working as an OTR truck driver requires prolonged sitting. Mining engineer, nursing instructors, and rumba dance instructors are less immobile.

Which assessment finding is most important in determining nursing care for a client with acute glomerulonephritis? A) Presence of albumin in the urine B) Dark smoky colored urine C) Blurred vision D) Peripheral edema

Ans: C Feedback: Visual disturbances can be indicative of rising blood pressure in a client with acute glomerulonephritis. Severe hypertension needs prompt treatment to prevent convulsions. Presence of albumin (protein) and RBCs in the urine, along with periorbital and peripheral edema, are common symptoms associated with glomerulonephritis.

A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication? A) Decrease in the blood flow through the kidneys B) Obstruction of urine flow from the kidneys C) Blood clot formed in the kidneys interfered with the flow D) Structural damage occurred in the nephrons of the kidneys

Ans: A Feedback: Acute renal failure can be caused by poor perfusion and/or decrease in circulating volume results from hypovolemic shock. Obstruction of urine flow from the kidneys through blood clot formation and structural damage can result in postrenal disorders but not indicated in this client.

A client with end-stage renal disease is scheduled to undergo a kidney transplant using a sibling donated kidney. The client asks if immunosuppressive drugs can be avoided. Which is the best response by the nurse? A) "Even a perfect match does not guarantee organ rejection." B) "Immunosuppressive drugs guarantee organ success." C) "The doctor may decide to delay the use of immunosuppressant drugs." D) "Let's wait until after the surgery to discuss your treatment plan."

Ans: A Feedback: Even a perfect match does not guarantee that a transplanted organ will not be rejected. Immunosuppressive drugs are used in all organ transplants to decrease incidence of organ rejection. To provide the client with the information needed to provide informed consent, the treatment plan is reviewed and discussed prior to transplant.

An elderly client is being evaluated for suspected pyelonephritis and is ordered kidney, ureter, and bladder (KUB) x-ray. The nurse understands the significance of this order is related to which rationale? A) Shows damage to the kidneys B) If risk for chronic pyelonephritis is likely C) Reveals causative microorganisms D) Detects calculi, cysts, or tumors

Ans: D Feedback: Urinary obstruction is the most common cause of pyelonephritis in the older adult. A KUB may reveal obstructions such as calculi, cysts, or tumors. KUB is not indicated for detection of impaired renal function or reveal increased risk for chronic form of the disorder. Urine cultures will reveal causative microorganisms present in the urine.

A client has undergone a renal transplant and returns to the healthcare agency for a follow- up evaluation. Which finding would lead to the suspicion that the client is experiencing rejection? A) Hypotension B) Weight loss C) Polyuria D) Abdominal pain

Ans: D Feedback: Signs and symptoms of transplant rejection include abdominal pain, hypertension, weight gain, oliguria, edema, fever, increased serum creatinine levels, and swelling or tenderness over the transplanted kidney site.

A client is diagnosed with polycystic kidney disease. Which of the following would the nurse most likely assess? A) Hypertension B) Flank pain C) Fever D) Periorbital edema

Ans: A Feedback: Hypertension is present in approximately 75% of clients with polycystic kidney disease at the time of diagnosis. Pain from retroperitoneal bleeding, lumbar discomfort, and abdominal pain also may be noted based on the size and effects of the cysts. Fever would suggest an infection. Periorbital edema is noted with acute glomerulonephritis.

The nurse is providing supportive care to a client receiving hemodialysis in the management of acute renal failure. Which statement from the nurse best reflects the ability of the kidneys to recover from acute renal failure? A) The kidneys can improve over a period of months. B) Once on dialysis, the need will be permanent. C) Kidney function will improve with transplant. D) Acute renal failure tends to turn to end-stage failure.

Ans: A Feedback: The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months. As long as recovery is continuing, there is no need to consider transplant or permanent hemodialysis. Acute renal failure can progress to chronic renal failure.

The nurse is caring for several older clients. Which client would the nurse be especially alert for signs and symptoms of pyelonephritis? A) A client with acute renal failure B) A client with a urinary tumor C) A female client with preexisting chronic glomerulonephritis D) A client with urinary obstruction

Ans: D Feedback: The client with urinary obstruction is at the highest risk of developing pyelonephritis because a urinary obstruction is the most common cause of pyelonephritis in older adults. Acute glomerulonephritis usually occurs in older adults with preexisting chronic glomerulonephritis. Older clients with acute renal failure or urinary tumor are not at high risk for developing pyelonephritis.

When preparing a client for hemodialysis, which of the following would be most important for the nurse to do? A) Check for thrill or bruit over the access site. B) Inspect the catheter insertion site for infection. C) Add the prescribed drug to the dialysate. D) Warm the solution to body temperature.

Ans: A Feedback: When preparing a client for hemodialysis, the nurse would need to check for a thrill or bruit over the vascular access site to ensure patency. Inspecting the catheter insertion site for infection, adding the prescribed drug to the dialysate, and warming the solution to body temperature would be necessary when preparing a client for peritoneal dialysis.

A nephrostomy tube is inserted in a client with a large ureteral calculus. Which is the most important consideration in providing nursing care for this client? A) Clamp the tube for no longer than 2 hours at a time. B) Maintain free, continuous urine drainage. C) Leave nephrostomy site open to the air. D) Use only sterile NSS to irrigate the tube.

Ans: B Feedback: Clamping or kinking of the tube will create backup of urine into the renal pelvis, resulting in hydronephrosis and can contribute to renal damage. Always make sure the urine is allowed to flow continuously and freely and do not irrigate. The nephrostomy tube is inserted through a stab wound and enters the kidney. A sterile dressing should be used to prevent pathogen entry.

26. The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom? A) Azotemia B) Diminished erythropoietin production C) Impaired immunologic response D) Electrolyte imbalances

Ans: B Feedback: Erythropoietin is a hormone produced in the kidneys, and this production is inadequate in chronic renal failure, which results in anemia. Azotemia, impaired immune response, and electrolyte imbalance are associated with chronic renal failure but not indicated with anemia.

A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values? A) Elevated urea levels B) Hyperkalemia C) Hypocalcemia D) Elevated white blood cells

Ans: B Feedback: Hyperkalemia is the life-threatening effect of renal failure. The client can become apathetic; confused; and have abdominal cramping, dysrhythmias, nausea, muscle weakness, and numbness of the extremities. Symptoms of hypocalcemia are muscle twitching, irritability, and tetany. Elevation in urea levels can result in azotemia, which can be exhibited in fluid and electrolyte and/or acid-base imbalance. Elevation of WBCs is not indicated.

An investment banker, with chronic renal failure, informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse? A) "The risk of peritonitis is greater with this type of dialysis." B) "This type of dialysis will provide more independence." C) "Peritoneal dialysis will require more work for you." D) "Peritoneal dialysis does not work well for every client."

Ans: B Feedback: Once a treatment choice has been selected by the client, the nurse should support the client in that decision. Continuous cyclic peritoneal dialysis will provide more independence for this client and supports the client's decision for treatment mode. The risk of peritonitis is greater, and symptoms should be discussed as part of the management of the disorder. Peritoneal dialysis is an effective method of dialysis for many clients.

After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching? A) "It is important to use strict aseptic technique." B) "It is appropriate to warm the dialysate in a microwave." C) "The infusion clamp should be open during infusion." D) "The effluent should be allowed to drain by gravity."

Ans: B Feedback: The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag.

When assessing a client with chronic glomerulonephritis, the nurse notes that the client has generalized edema. The nurse documents this as which of the following? A) Periorbital edema B) Anasarca C) Uremic frost D) Hydronephrosis

Ans: B Feedback: Generalized edema known as anasarca is a common finding with chronic glomerulonephritis. Periorbital edema refers to puffiness around the eyes. Uremic frost is a precipitate that forms on the skin in clients with chronic renal failure. Hydronephrosis refers to a condition involving distention of the renal pelvis.

The nurse evaluates the client as experiencing symptoms of disequilibrium syndrome, following an initial hemodialysis treatment. Which is the best action to be taken by the nurse? A) No action is needed. B) Hold the next scheduled treatment. C) Slow the dialysis process during future treatment. D) Notify the physician and manage the symptoms.

Ans: C Feedback: Disequilibrium syndrome is a neurologic condition believed to be caused by cerebral edema associated with rapid movement of water. The symptoms are self-limiting and disappear within several hours after dialysis but can be prevented by slowing the dialysis process to allow time for gradual equilibrium of water. The nurse should document the symptoms and notify the physician with repeated incidence.

A client with several calculi in the ureter is scheduled for extracorporeal shock wave lithotripsy (ESWL). Which teaching statement by the nurse best describes the procedure? A) A scope is passed through the urethra to visualize and destroy the stones with a laser. B) After locating the calculi, a small incision is made to remove the stones. C) The stone is identified via fluoroscopy and then shock waves are used to shatter the stones. D) Once the calculi are located, a fine wire delivers shock waves to pulverize the stones.

Ans: C Feedback: ESWL is a procedure that uses 800 to 2400 shock waves aimed from outside the body toward soft tissues to dense stones. The repetition of the shock waves helps to shatter the stones into smaller particles that can be passed from the urinary tract. No incision is needed for ESWL therapy. Laser lithotripsy uses a fine wire placement to allow the laser beam to pulverize the stones.

A chronic renal failure client complains of generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? A) Elevated serum creatinine B) Hyperkalemia C) Hyperphosphatemia D) Elevated urea and nitrogen

Ans: C Feedback: Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia. In an effort to raise blood calcium levels, the parathyroid glands secrete more parathormone. Elevated creatinine, urea, nitrogen, and potassium levels are expected in chronic renal failure and do not contribute to bone fractures.

The client with glomerulonephritis is exhibiting gross periorbital edema. Which is the best nursing intervention to relieve this symptom? A) Administer diuretics. B) Apply warm compresses. C) Elevate the head of the bed. D) Monitor intake and output.

Ans: C Feedback: Periorbital edema can be managed with positioning the client with an HOB elevation. Cool compresses can be helpful. Diuretics, required as an order by the physician, are used to treat symptoms of edema and hypertension in clients with glomerulonephritis. Monitoring intake and output is an essential nursing measure but not specific to perioribital edema relief.

A client is diagnosed with polycystic kidney disease and requires teaching on the management of the disorder. Which statement made by the client indicates a need for further teaching? A) "I inherited this disorder from one of my parents." B) "The cysts can get quite large in size." C) "As long as I have one normal kidney, I should be fine." D) "If renal failure develops, I may need to consider dialysis."

Ans: C Feedback: Polycystic kidney disease is characterized by the formation of multiple cysts on both kidneys. Polycystic kidney disease is inherited as an autosomal dominant trait. The fluid- filled cysts can cause great enlargement of the kidneys and interfere with kidney function, which can eventually lead to renal failure.

A client with newly diagnosed renal cancer is questioning why detection was delayed. Which is the best response by the nurse? A) "Squamous cell carcinomas do not present with detectable symptoms." B) "You should have sought treatment earlier." C) "Very few symptoms are associated with renal cancer." D) "Painless gross hematuria is the first symptom in renal cancer."

Ans: C Feedback: Renal cancers rarely cause symptoms in the early stage. Tumors can become quite large before causing symptoms. Painless, gross hematuria is often the first symptom in renal cancer and does not present until later stages of the disease. Adenocarcinomas are the most common renal cancer (about 80%), whereas squamous cell renal cancers are rare. It is not therapeutic to place doubt or blame for delayed diagnosis.

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect? A) Acute glomerulonephritis B) Ureteral stricture C) Urinary calculi D) Renal cell carcinoma

Ans: C Feedback: Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; however, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi. The pain is accompanied by renal or ureteral colic, painful spasms that attempt to move the stone. The pain comes in waves that radiate to the inguinal ring, the inner aspect of the thigh, and to the testicle or tip of the penis in men, or the urinary meatus or labia in women. Clients with acute glomerulonephritis may be asymptomatic or may exhibit fever, nausea, malaise, headache, edema (generalized or periorbital), pain, and mild to moderate hypertension. Clients with ureteral stricture may complain of flank pain and tenderness at the costovertebral angle and back or abdominal discomfort. A client with renal cell carcinoma rarely exhibits symptoms early on but may present with painless hematuria and persistent back pain in later stages.

Following a nephrectomy, which assessment finding is most important in determining nursing care for the client? A) Urine output of 35 to 40 mL/hour B) Pain of 3 out of 10, 1 hour after analgesic administration C) SpO2 at 90% with fine crackles in the lung bases D) Blood tinged drainage in Jackson-Pratt drainage tube

Ans: C Feedback: The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients post nephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sounds. Intake and output is monitored to maintain a urine output of greater than 30 mL/hour. Pain control is important and should allow for movement, deep breathing, and rest. Blood-tinged drainage from the JP tube is expected in the initial postoperative period.

A client is administered dialysate solution through an abdominal catheter. The nurse notices that the return flow rate is slow, so the nurse advises the client to move to the other side. However, even after changing the client's position, the nurse does not observe an increase in return flow. Which of the following actions should the nurse perform to help accelerate the return flow rate? A) Disconnect the catheter and reapply. B) Loosen the tubing clamp. C) Inform the physician that catheter may need repositioning. D) Stop the process for 5 minutes and resume later.

Ans: C Feedback: The nurse instills dialysate solution and clamps the tubing. If the return flow rate is slow, the nurse asks the client to move from side to side. If this maneuver is unsuccessful, the physician may need to reposition the catheter. The nurse should not tamper with the catheter settings because this may worsen the client's condition or damage the apparatus. Also, stopping the process and resuming it after 5 minutes will not help increase the return flow of the dialysate.

A nurse identifies a nursing diagnosis of Risk for Ineffective Breathing Pattern related to incisional pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care? A) Administer isotonic fluid therapy as ordered. B) Keep the drainage catheter below the level of insertion. C) Encourage use of incentive spirometer every 2 hours. D) Monitor temperature every 4 hours.

Ans: C Feedback: To address the issue of ineffective breathing pattern, encouraging the use of incentive spirometer would be most appropriate to help increase alveolar ventilation. Administering isotonic fluid therapy would be appropriate for issues involving fluid loss such as bleeding or hemorrhage. Keeping the drainage catheter below the level of insertion would be appropriate to reduce the risk of obstruction leading to acute pain. Monitoring the temperature every 4 hours would be appropriate to reduce the client's risk for infection.

The client with chronic renal failure complains of intense itching. Which assessment finding would indicate the need for further nursing education? A) Pats skin dry after bathing B) Uses moisturizing creams C) Keeps nails trimmed short D) Brief, hot daily showers

Ans: D Feedback: Hot water removes more oils from the skin and can increase dryness and itching. Tepid water temperature is preferred in the management of pruritus. The use of moisturizing lotions and creams that do not contain perfumes can be helpful. Avoid scratching and keeping nails trimmed short is indicated in the management of pruritus.