practice test 2

A female client is experiencing bladder control problems. Which outcome indicates the success of nursing interventions to promote urinary continence for this client? a) continence for 24 hours a day b) self-monitoring for urine retention c) improvement in bladder control d) compliance with drinking and voiding schedule

a) continence for 24 hours a day Self-monitoring for urine retention is an important aspect of achieving the outcome, but it addresses only one area and does not reflect goal achievement. The same is true for compliance with the drinking and voiding schedule.

To assess the client's renal status, the nurse should monitor which laboratory tests? Select all that apply. a) creatinine levels b) arterial blood gases c) hemoglobin d) serum blood urea nitrogen (BUN) e) urinalysis f) potassium levels g) serum sodium

a) creatinine levels d) serum blood urea nitrogen (BUN) -Serum BUN and creatinine are the tests most commonly used to assess renal function, with creatinine being the most reliable indicator. -Nonrenal factors may affect BUN levels as well as serum sodium and potassium levels. -Arterial blood gases and hemoglobin are not used to assess renal status. -Urinalysis is a general screening test.

A client is experiencing hypovolemic shock. Which of the following assessments best assists in evaluating the client's fluid status? Select all that apply. a) Respiratory rate b) Blood pressure c) Hemoglobin level d) Daily weight e) Skin turgor f) Heart rate

a) Respiratory rate b) Blood pressure d) Daily weight e) Skin turgor f) Heart rate -With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. -As compensatory mechanisms, heart and respiratory rates generally increase with both fluid volume deficit and overload, making those assessment essential. -Skin turgor and daily weights are essential assessments in the client with any fluid imbalance. -The hemoglobin level reflects red blood cell concentration, not overall fluid status.

A client with chronic renal failure is experiencing metabolic acidosis. The client most likely requires: a) peritoneal dialysis b) no treatment c) sodium bicarbonate supplements d) hemodialysis

b) no treatment

The primary reason for taping an indwelling catheter laterally to the thigh of a male client is to: a) prevent accidental catheter removal. b) prevent the catheter from kinking in the urethra. c) eliminate pressure at the penoscrotal angle. d) allow the client to turn without kinking the catheter.

c) eliminate pressure at the penoscrotal angle.

The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included? a) Ignore the urge to void. b) Ask for the bedpan. c) Ring for assistance to go to the bathroom. d) Increase intake of fluids.

d) Increase intake of fluids

The nurse is assessing the urine of a client who has had an ileal conduit and notes that there is a moderate amount of mucus. The nurse should: a) change the appliance bag. b) notify the health care provider (HCP). c) obtain a urine specimen for culture. d) encourage a high fluid intake.

d) encourage a high fluid intake. Mucus is secreted by the intestinal segment used to create the conduit and is a normal occurrence. The client should be encouraged to maintain a large fluid intake to help flush the mucus out of the conduit. Because mucus in the urine is expected, it is not necessary to change the appliance bag or to notify the HCP. The mucus is not an indication of an infection, so a urine culture is not necessary.

A client has cystitis. The nurse should further assess the client for: a) oliguria. b) flank pain. c) nausea and vomiting. d) foul-smelling urine.

d) foul-smelling urine. Foul-smelling urine is indicative of cystitis. Other symptoms include dysuria and urinary frequency and urgency. Flank pain, nausea, and vomiting indicate pyelonephritis.

The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which statements indicate that the client has correctly understood the teaching? Select all that apply. a) "I must use a skin barrier to protect my skin from urine." b) "If I limit my fluid intake, I will not have to empty my ostomy pouch as often." c) "I should empty my ostomy pouch of urine when it is full." d) "I can place an aspirin tablet in my pouch to decrease odor." e) "I can usually keep my ostomy pouch on for 3 to 7 days before changing it."

a) "I must use a skin barrier to protect my skin from urine." e) "I can usually keep my ostomy pouch on for 3 to 7 days before changing it." -The client with an ileal conduit must learn self-care activities related to care of the stoma and ostomy appliances. -The client should be taught to increase fluid intake to about 3,000 mL/day and should not limit intake. -Adequate fluid intake helps to flush mucus from the ileal conduit. -The ostomy appliance should be changed approximately every 3 to 7 days and whenever a leak develops. -A skin barrier is essential to protecting the skin from the irritation of the urine. -An aspirin should not be used as a method of odor control because it can be an irritant to the stoma and lead to ulceration. -The ostomy pouch should be emptied when it is one-third to one-half full to prevent the weight of the urine from pulling the appliance away from the skin.

A client has been prescribed nitrofurantoin for treatment of a lower urinary tract infection. Which instructions should the nurse include when teaching the client how to take this medication? Select all that apply. a) "Increase your fluid intake." b) "Take the medication until your symptoms subside." c) "Take the medication on an empty stomach." d) "Your urine may become brown in color." e) "Take the medication with an antacid to decrease gastrointestinal distress."

a) "Increase your fluid intake." d) "Your urine may become brown in color." Clients who are taking nitrofurantoin should be instructed to take the medication with meals and to increase their fluid intake to minimize gastrointestinal distress. The urine may become brown in color. Although this change is harmless, clients need to be prepared for this color change. The client should be instructed to take the full prescription and not to stop taking the drug because symptoms have subsided. The medication should not be taken with antacids as this may interfere with the drug's absorption.

A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse include in the discharge instructions? Select all that apply. a) Drink at least 3,000 mL of fluid each day. b) Avoid odor-producing foods, such as onions, fish, eggs, and cheese. c) Wear snug clothing over the stoma to encourage urine flow into the drainage bag. d) Keep urine alkaline to prevent urinary tract infections. e) Minimize daily activities.

a) Drink at least 3,000 mL of fluid each day. b) Avoid odor-producing foods, such as onions, fish, eggs, and cheese. An adequate fluid intake aids in the prevention of urinary calculi and infection. Odor-producing foods can produce offensive odors that may impact the client's lifestyle and relationships. Lack of activity leads to urinary stasis, which promotes urinary calculi development and infection. Acidic urine helps prevent urinary tract infections. Tight clothing over the stoma obstructs blood circulation and urine flow.

A client has been admitted with acute renal failure. What should the nurse do? Select all that apply. a) Establish an IV access site. b) Take vital signs. c) Elevate the head of the bed 30 to 45 degrees. d) Call the admitting health care provider (HCP) for prescriptions. e) Contact the hemodialysis unit.

a) Establish an IV access site. b) Take vital signs. c) Elevate the head of the bed 30 to 45 degrees. d) Call the admitting health care provider (HCP) for prescriptions. Elevation of the head of the bed will promote ease of breathing. Respiratory manifestations of acute renal failure include shortness of breath, orthopnea, crackles, and the potential for pulmonary edema. Therefore, priority is placed on facilitation of respiration. The nurse should assess the vital signs because the pulse and respirations will be elevated. Establishing a site for IV therapy will become important because fluids will be administered IV in addition to orally. The HCP will need to be contacted for further prescriptions; there is no need to contact the hemodialysis unit.

An 80-year-old client had spinal anesthesia for a transurethral resection of the prostate and received 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care? a) Hang new bags of irrigation. b) Cover the client with warm blankets. c) Empty the catheter drainage bag. d) Turn the client.

b) Cover the client with warm blankets. -It is important for the nurse to cover this client with warm blankets because he is at high risk for hypothermia secondary to age, spinal anesthesia, placement in a lithotomy position in the cool operating room for 1.5 hours, instillation of 4,000 mL of room temperature bladder irrigation, and ongoing bladder irrigation. -Spinal anesthesia causes vasodilation, which results in heat loss from the core to the periphery. -The nurse will empty the catheter drainage bag and hang new bags of irrigation as needed, but the client's potential for hypothermia should be addressed first. The client will not be turned at this time.

The nurse teaches a client scheduled for an I.V. pyelogram what to expect when the dye is injected. The client has correctly understood what was taught when the client states that there may be which of the following sensations when the dye is injected? a) Chest pain. b) Flushing of the face. c) A metallic taste. d) Cold chills.

b) Flushing of the face. As the dye is injected, the client may experience a feeling of warmth, flushing of the face, and a salty taste in the mouth. The client should not experience chest pain or cold chills; these would be adverse reactions warranting close monitoring of the client.

The nurse is caring for a client who possibly may need kidney dialysis. When evaluating the client's renal function to report to the health care provider, which data will the nurse use? Select all that apply. a) Trending vital signs b) Glomerular filtration rate c) Serum creatinine level d) A client's 24-hour urinary output e) A client's flank pain level f) The blood count report

b) Glomerular filtration rate c) Serum creatinine level d) A client's 24-hour urinary output -When evaluating renal functioning, the nurse would report to the health care provider information on their current urine output, the glomerular filtration rate, and serum creatinine levels which identify the degree of kidney dysfunction. -This objective data provides diagnostic information. -Vital signs and pain level reflect the impact of the renal disease. - Blood count reports to do not assist in evaluating renal function.

When caring for a client with a history of benign prostatic hypertrophy (BPH), what should the nurse do? Select all that apply. a) Catheterize the client for post void residual urine. b) Provide privacy and time for the client to void. c) Monitor intake and output. d) Ask the client if he has urinary retention. e) Test the urine for hematuria.

b) Provide privacy and time for the client to void. c) Monitor intake and output. d) Ask the client if he has urinary retention. e) Test the urine for hematuria. -It is not necessary to catheterize the client.

A client had a lithotripsy to treat renal calculi. The client is having ureteral spasms and hematuria. What should the nurse do? Select all that apply. a) Encourage fluid intake of 1,000 ml/day. b) Strain all urine. c) Contact the health care provider (HCP) to report hematuria. d) Assess pain level. e) Apply a heating pad to the lower back area.

b) Strain all urine. d) Assess pain level. e) Apply a heating pad to the lower back area. Following lithotripsy, the nurse strains all urine to collect and identify stone composition. Providing heat to the flank area may be helpful to relieve muscle spasms when renal colic is present; the nurse assesses the client's pain level and administers analgesics as needed. Hematuria is common after lithotripsy, and it is not necessary to notify the HCP. The nurse should promote a fluid intake of at least 2,000 ml/day to flush stones and clots through the urinary tract.

The nurse is caring for a client with urinary calculi of unknown origin. Which of the following interventions would be appropriate for this client? Select all that apply. a) Decrease calcium intake b) Strain urine c) Administer allopurinol d) Restrict fluid e) Medicate for pain

b) Strain urine e) Medicate for pain -Strain the urine to obtain the stone and send it for analysis, which will assist the healthcare provider in determining the correct course of treatment to prevent a recurrence. -Urinary calculi are very painful and require pain medication. -Client needs to increase fluid to flush out the stone. -It is not appropriate to decrease calcium until it is determined that the stone consists of calcium. -Allopurinol would only be ordered if the stone consisted of uric acid.

A client has been prescribed allopurinol for renal calculi that are caused by high uric acid levels. Which symptoms indicate the client is experiencing adverse effect of this drug? Select all that apply. a) constipation b) rash c) nausea d) flushed skin e) bone marrow depression

b) rash c) nausea e) bone marrow depression -Common adverse effects of allopurinol include gastrointestinal distress, such as anorexia, nausea, vomiting, and diarrhea. -A rash is another potential adverse effect. -A potentially life-threatening adverse effect is bone marrow depression. -Constipation and flushed skin are not associated with this drug.

In addition to nausea and severe flank pain, a female client with renal calculi has pain in the groin and bladder. The nurse should assess the client further for signs of: a) additional stone formation. b) referred pain. c) urine retention. d) nephritis.

b) referred pain. -The pain associated with renal colic due to calculi is commonly referred to the groin and bladder in female clients and to the testicles in male clients. -Nausea, vomiting, abdominal cramping, and diarrhea may also be present. -Nephritis or urine retention is an unlikely cause of the referred pain. -The type of pain described in this situation is unlikely to be caused by additional stone formation.

The nurse is reviewing a client's urine culture and sensitivity test results. Which findings would the nurse expect to see in small amounts in normal urine? Select all that apply. a) Ketones. b) Bilirubin. c) Protein. d) Nitrates. e) White blood cells. f) Crystals.

c) Protein. e) White blood cells. -Small amounts of protein and white blood cells are normal. -Ketones, crystals, nitrates, and bilirubin are all abnormal findings.

A client on a low-phosphate diet receives a breakfast tray that includes scrambled eggs, cream of wheat cereal, strawberries, coffee, and low-fat milk. Which of the following is the nurse's best action? a) Explain to the client why he or she cannot eat the eggs b) Replace the strawberries with an apple c) Remove the milk carton from the tray d) Order the client a new breakfast tray

c) Remove the milk carton from the tray Foods high in phosphate include milk, other dairy products, bran, organ meats, some fish, and dried beans and peas. By removing the milk from the tray the nurse will maintain the client on the prescribed low-phosphate diet. Fruits and eggs are not high in phosphate and are not restricted.

A charge nurse is completing day-shift client care assignments on the genitourinary floor. A new graduate is present for her first day on the unit. An agency nurse and an experienced nurse are also present on the unit. The charge nurse should assign the new graduate to the care of: a) an elderly client just admitted for acute stroke, a young adult client with suspected kidney stones, and a middle-age client with suspected pyelonephritis. b) a client who had an ileo conduit 3 days ago, an elderly client with a urinary tract infection (UTI), and an adolescent with kidney stones. c) an elderly client with bladder cancer awaiting surgery, an elderly client who had a prostatectomy and bladder irrigation 2 days ago, and an elderly client with renal insufficiency. d) a middle-age client who had a kidney transplant 3 days ago, an elderly client in acute renal failure, and an elderly client with urinary sepsis.

c) an elderly client with bladder cancer awaiting surgery, an elderly client who had a prostatectomy and bladder irrigation 2 days ago, and an elderly client with renal insufficiency. The charge nurse should assign the new nurse to the elderly client newly diagnosed with bladder cancer awaiting surgery, the elderly client who recently had a prostatectomy with bladder irrigation, and the elderly client with renal insufficiency. These clients have conditions common to the genitourinary floor. The charge nurse should assign the agency nurse to the client who had an ileo conduit, the older adult client with a UTI, and the adolescent with kidney stones. Their conditions have lesser acuity. The charge nurse should assign the experienced nurse to the most acute clients: the middle-age kidney-transplant recipient, the older adult client in acute renal failure, the older adult client with urinary sepsis, the older adult client just admitted for acute stroke, the young adult client with suspected kidney stones, and the middle-age client with suspected pyelonephritis.

The client's serum potassium level is elevated in acute renal failure, and the nurse administers sodium polystyrene sulfonate. The mechanism of action for this drug is to: a) release hydrogen ions for sodium ions. b) increase calcium absorption in the colon. c) exchange sodium for potassium ions in the colon. d) increase potassium excretion from the colon.

c) exchange sodium for potassium ions in the colon. Polystyrene sulfonate, a cation-exchange resin, causes the body to excrete potassium through the gastrointestinal tract. In the intestines, particularly the colon, the sodium of the resin is partially replaced by potassium. The potassium is then eliminated when the resin is eliminated with feces. Although the result is to increase potassium excretion, the specific method of action is the exchange of sodium ions for potassium ions. Polystyrene sulfonate does not release hydrogen ions or increase calcium absorption.

When emptying the client's bladder during a urinary catheterization, the nurse should allow the urine to drain from the bladder slowly to prevent: a) renal failure. b) abdominal cramping. c) possible shock. d) atrophy of bladder musculature.

c) possible shock. Rapid emptying of an overdistended bladder may cause hypotension and shock due to the sudden change of pressure within the abdominal viscera. The nurse should empty the bladder slowly. Removal of urine from the bladder does not cause renal failure. The client may experience cramping, but the primary concern is the potential for shock. Bladder muscles will not atrophy because of a catheterization.

Allopurinol, 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which adverse effect of this medication? a) dizziness b) nasal congestion c) retinopathy d) maculopapular rash

d) maculopapular rash Allopurinol is used to treat renal calculi composed of uric acid. Adverse effects of allopurinol include drowsiness, maculopapular rash, anemia, abdominal pain, nausea, vomiting, and bone marrow depression. Clients should be instructed to report rashes and unusual bleeding or bruising. Retinopathy, nasal congestion, and dizziness are not adverse effects of allopurinol.

After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which complication related to this pelvic surgery? a) peritonitis b) ascites c) inguinal hernia d) thrombophlebitis

d) thrombophlebitis After pelvic surgery, there is an increased chance of thrombophlebitis owing to the pelvic manipulation that can interfere with circulation and promote venous stasis. Peritonitis is a potential complication of any abdominal surgery, not just pelvic surgery. Ascites is most frequently an indication of liver disease. Inguinal hernia may be caused by an increase in intra-abdominal pressure or a congenital weakness of the abdominal wall; ventral hernia occurs at the site of a previous abdominal incision.