Prioritization, Delegation, and Assignment Chapter 16

A patient has urolithiasis and is passing the stones into the lower urinary tract. What is the priority nursing diagnosis for the patient at this time? 1) Acute pain. 2) Risk for Infection. 3) Risk for Injury. 4) Anxiety related to the risk for recurrent stones.

Acute pain.

You are the admitting nurse for a patient with nephrotic syndrome. Which assessment finding supports this diagnosis? 1) Edema formation. 2) Hypotension. 3) Increased urine output. 4) Flank pain.

Edema formation.

The nursing diagnosis of Constipation related to compression of the intestinal tract has been identified in a patient with polycystic kidney disease. Which nursing care action should you delegate to a newly-trained LPN/LVN? 1) Instructing the patient about foods that are high in fiber. 2) Teaching the patient about foods that assist in promoting bowel regularity. 3) Assessing the patient for previous bowel problem and bowel routine. 4) Administering docusate sodium (Colace) 100 mg by mouth twice a day.

Administering docusate sodium (Colace) 100 mg by mouth twice a day.

You are admitting a 66-year-old male patient suspected of having a urinary tract infection (UTI). Which piece of the patient's medical history supports this diagnosis? 1) Patient's wife had a UTI 1 month ago. 2) Followed for prostate disease for 2 years. 3) Intermittent catheterization 6 months ago. 4) Kidney stone removal 1 year ago.

Followed for prostate disease for 2 years.

You are teaching a patient how best to prevent renal trauma after an injury that required a left nephrectomy. Which points would you include in your teaching plan? SELECT ALL THAT APPLY. 1) Always wear a seat belt. 2) Avoid all contact sports. 3) Practice safe walking habits. 4) Wear protective clothing to participate in contact sports. 5) Use caution when riding a bicycle.

Always wear a seat belt. Avoid all contact sports. Practice safe walking habits. Use caution when riding a bicycle.

A patient in whom acute kidney failure has been diagnosed has had a urine output of 1560 mL for the past 8 hours. The LPN/LVN who is caring for this patient, under your supervision, asks you how a patient with kidney failure can have such a large urine output. What is your best response? 1) "The patient's kidney failure was due to hypovolemia and we have given him IV fluids to correct the problem." 2) "Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day." 3) "With that much urine output, there must have been a mistake in the patient's diagnosis." 4) "An increase in urine output like this is an indicator that the patient is entering the recovery phase of acute kidney failure."

"Acute kidney failure patients go through a diuretic phase when their kidneys begin to recover and may put out as much as 10 L of urine per day."

You are supervising a senior nursing student who is caring for a 78-year-old scheduled for an intravenous pyelography. What information would you be sure to stress about this procedure to the nursing student? 1) "After the procedure, monitor urine output because the contrast dye increases the risk for kidney failure in older adults." 2) "The purpose of this procedure is to measure kidney size." 3) "Because this procedure assesses kidney function, there is no need for a bowel prep." 4) "Keep the patient NPO after the procedure because during the procedure the patient will receive drugs that affect the gag reflex."

"After the procedure, monitor urine output because the contrast dye increases the risk for kidney failure in older adults."

A patient with incontinence will be taking oxybutynin chloride (Ditropan) 5 mg by mouth three times a day after discharge. Which information would you be sure to teach this patient before discharge? 1) "Drink fluids or use hard candy when you experience a dry mouth." 2) "Be sure to notify your physician if you experience a dry mouth." 3) " If necessary, your physician can increase your dose up to 40 mg/day." 4) "You should take this medication with meals to avoid stomach ulcers."

"Drink fluids or use hard candy when you experience a dry mouth."

A UAP reports to you that a patient with acute kidney failure has had a urine output of 350 mL over the past 24 hours after receiving furosemide 40 mg IV push. The UAP asks you how this can happen. What is your best response? 1) "During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics." 2) "There must be some sort of error. Someone must have failed to record the urine output." 3) "A patient with acute kidney failure retains sodium and water, which counteracts the action of the furosemide." 4) "The gradual accumulation of nitrogenous waste products results in the retention of water and sodium."

"During the oliguric phase of acute kidney failure, patients often do not respond well to either fluid challenges or diuretics."

A 28-year-old married female patient with cystitis requires instruction about how to prevent future UTIs, and you have delegated this teaching to a newly-graduated RN. Which statement by the new nurse requires that you intervene? 1) "You should always drink 1 to 3 L of fluid every day." 2) "Empty your bladder regularly even if you do not feel the urge to urinate." 3) "Drinking cranberry juice daily will decrease the number of bacteria in your bladder." 4) "It's okay to soak in the tub with bubble bath because it will keep you clean."

"It's okay to soak in the tub with bubble bath because it will keep you clean."

A patient has renal cell carcinoma (adenocarcinoma of the kidney). You are providing orientation to a new nurse on the unit, who asks you why this patient is not receiving chemotherapy. What is your best response? 1) "The prognosis for this form of cancer is very poor, and we will be providing only comfort measures." 2) "Nephrectomy is the preferred treatment as chemotherapy has been shown to have only limited effectiveness against this type of cancer." 3) "Research has shown that the most effective means of treating this form of cancer is with radiation therapy." 4) "Radiofrequency ablation is a minimally invasive procedure that is the best way to treat renal cell carcinoma."

"Nephrectomy is the preferred treatment as chemotherapy has been shown to have only limited effectiveness against this type of cancer."

You are supervising a nurse on orientation to the unit who is discharging a patient admitted with kidney stones who underwent lithotripsy. Which statement by the nurse to the patient requires that you intervene? 1) "You should finish all of your antibiotics to make sure that you don't get a UTI." 2) "Remember to drink at least 3 L of fluids every day to prevent another stone from forming." 3) "Report any signs of bruising to your physician immediately, since this indicates bleeding." 4) "You can return to work in 2 days to 6 weeks, depending on what your physician prescribes."

"Report any signs of bruising to your physician immediately, since this indicates bleeding."

You are supervising a new RN graduate who is on orientation to the unit. The new RN asks you why the patient with uncomplicated cystitis is being discharged with orders for ciprofloxacin (Cipro) 250 mg twice a day for only 3 days. What is your best response? 1) "We should check with the physician, because the patient should take this drug for 10 to 14 days." 2) "A 3-day course of ciprofloxacin is not the appropriate treatment for a patient with uncomplicated cystitis." 3) "Research has shown that, with a 3-day course of ciprofloxacin, there is increased patient adherence to the plan of care." 4) "Longer courses of antibiotic therapy are required for hospitalized patients to prevent nosocomial infections."

"Research has shown that, with a 3-day course of ciprofloxacin, there is increased patient adherence to the plan of care."

You are caring for a patient admitted with dehydration secondary to deficient antidiuretic hormone (ADH). Which specific gravity value supports this diagnosis? 1) 1.010 2) 1.035 3) 1.020 4) 1.002

1.002

As charge nurse, you must rearrange room assignments to admit a new patient. Which two patients would be best suited to be roommates? 1) 58-year-old with urothelial cancer receiving multiagent chemotherapy. 2) 63-year-old with kidney stones who has just undergone open ureterolithotomy. 3) 24-year-old with acute pyelonephritis and severe flank pain. 4) 76-year-old with urge incontinence and a UTI.

24-year-old with acute pyelonephritis and severe flank pain. 76-year-old with urge incontinence and a UTI.

As charge nurse, you would assign the nursing care of which patient to an LPN/LVN, working under the supervision of an RN? 1) 48-year-old with cystitis who is taking oral antibiotics. 2) 64-year-old with kidney stones who has a new order for lithotripsy. 3) 72-year-old with urinary incontinence who needs bladder training. 4) 52-year-old with pyelonephritis who has severe acute flank pain.

48-year-old with cystitis who is taking oral antibiotics.

In a male patient who must undergo intermittent catheterization, you are preparing to insert a catheter to assess the patient for postvoid residual. Place the steps for catheterization in the correct order. 1) Assist the patient to the bathroom and ask the patient to attempt to void. 2) Retract the foreskin and hold the penis at a 60- to 90-degree angle. 3) Open the catheterization kit and put on sterile gloves. 4) Lubricate the catheter and insert it through the meatus of the penis. 5) Position the patient supine in bed or with the head slightly elevated. 6) Drain all the urine present in the bladder into a container. 7) Cleanse the glans penis starting at the meatus and working outward. 8) Remove the catheter, clean the penis, and measure the amount of urine retained.

Assist the patient to the bathroom and ask the patient to attempt to void. Position the patient supine in bed or with the head slightly elevated. Open the catheterization kit and put on sterile gloves. Retract the foreskin and hold the penis at a 60- to 90-degree angle. Cleanse the glans penis starting at the meatus and working outward. Lubricate the catheter and insert it through the meatus of the penis. Drain all the urine present in the bladder into a container. Remove the catheter, clean the penis, and measure the amount of urine retained.

A patient on the medical-surgical unit with acute kidney failure is to begin continuous arteriovenous hemofiltration (CAVH) as soon as possible. What is the priority action at this time? 1) Call the charge nurse and transfer the patient to the ICU. 2) Develop a teaching plan for the patient that focuses on CAVH. 3) Assist the patient with morning bath and mouth care before transfer. 4) Notify the physician that the patient's mean arterial pressure is 68 mm Hg.

Call the charge nurse and transfer the patient to the ICU.

You are providing nursing care for a patient with acute kidney failure for whom a nursing diagnosis of Excess Fluid Volume related to compromised regulatory mechanisms has been identified. Which actions should you delegate to an experienced UAP? SELECT ALL THAT APPLY. 1) Measuring and recording vital sign values every 4 hours. 2) Weighing the patient every morning using a standing scale. 3) Administering furosemide (Lasix) 40 mg orally twice a day. 4) Reminding the patient to save all urine for intake and output measurement. 5) Assessing breath sounds every 4 hours. 6) Ensuring that the patient's urinal is within reach.

Measuring and recording vital sign values every 4 hours. Weighing the patient every morning using a standing scale. Reminding the patient to save all urine for intake and output measurement. Ensuring that the patient's urinal is within reach.

You are the charge nurse. Which patient will you assign to a nurse floated to your unit from the surgical intensive care unit (ICU)? 1) Patient with kidney stones scheduled for lithotripsy this morning. 2) Patient who has just undergone surgery for renal stent placement. 3) Newly-admitted patient with and acute UTI. 4) Patient with chronic kidney failure who needs teaching on peritoneal dialysis.

Patient who has just undergone surgery for renal stent placement.

You are creating a nursing care plan for older adult patients with incontinence. For which patient will a bladder-training program be an appropriate intervention? 1) Patient with functional incontinence caused by mental status changes. 2) Patient with stress incontinence due to weakened bladder neck support. 3) Patient with urge incontinence and abnormal detrusor muscle contractions. 4) Patient with transient incontinence related to loss of cognitive function.

Patient with urge incontinence and abnormal detrusor muscle contractions.

You are providing nursing care for a 24-year-old female patient admitted to the unit with a diagnosis of cystitis. Which intervention should you delegate to the UAP? 1) Teaching the patient how to secure a clean-catch urine sample. 2) Assessing the patient's urine for color, odor, and sediment. 3) Reviewing the nursing care plan and add nursing interventions. 4) Providing the patient with a clean-catch urine sample container.

Providing the patient with a clean-catch urine sample container.

You are providing care for a patient with reflex urinary incontinence. Which action could be appropriately delegated to a new LPN/LVN? 1) Teaching the patient bladder emptying by the Crede' method. 2) Demonstrating how to perform intermittent self-catheterization. 3) Discussing the side effects of bethanechol chloride (Urecholine). 4) Reinforcing the importance of proper hand washing to prevent infections.

Reinforcing the importance of proper hand washing to prevent infections.

Your patient is receiving IV piggyback doses of gentamicin (Garamycin) every 12 hours. Which would be your priority for monitoring during the period that the patient is receiving this drug? 1) Serum creatinine and blood urea nitrogen levels. 2) Patient weight every morning. 3) Intake and output every shift. 4) Temperature.

Serum creatinine and blood urea nitrogen levels.

A patient is being admitted to rule out interstitial cystitis. What should your plan of care for this patient include? 1) Take daily urine samples for urinalysis. 2) Maintain accurate intake and output records. 3) Obtain an admission urine sample to determine electrolyte levels. 4) Teach the patient about the cystoscopy procedure.

Teach the patient about the cystoscopy procedure.

Which laboratory result is of most concern to you for an adult patient with cystitis? 1) Serum white blood cell (WBC) count of 9000/mm3. 2) Urinalysis results showing 1 or 2 WBCs present. 3) Urine bacteria count of 100,000 colonies per millimeter. 4) Serum hematocrit of 36%.

Urine bacteria count of 100,000 colonies per millimeter.