Elimination PrepU N400 Fall 2021
A client reports an episode of losing control of urination when a bathroom wasn't close by. The client states, "I'm worried this means that I'm starting to lose control of my bladder." What is the appropriate nursing response? "I agree; please make an appointment with your health care provider." "This only happened one time, so it is nothing to worry about." "Let's review your medication history and whether you consume bladder irritants." "I suggest that you invest in incontinence undergarments."
"Let's review your medication history and whether you consume bladder irritants." Explanation: Urge incontinence can be aggravated by bladder irritants such as caffeine or alcohol, and can take place if diuretics are taken in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the health care provider, or to recommend incontinence undergarments.
A new client on hemodialysis is watching his blood being filtered through a dialyzer. He asks the nurse how much blood typically passes through the kidney every minute? The nurse responds: 100-300 mL/minute. 500-800 mL/minute. 1000-1300 mL/minute. 1700-2000 mL/minute.
1000-1300 mL/minute. Explanation: In the adult, the kidneys are perfused with 1000 to 1300 mL of blood per minute, or 20% to 25% of the cardiac output.
The nurse is recording the intake and output for a client: D5NS 1,000 ml, urine 450 ml, emesis 125 ml, Jackson-Pratt drain #1 35 ml, Jackson-Pratt drain #2 32 ml, and Jackson-Pratt drain #3 12 ml. How many milliliters would the nurse document as the client's output? Record your answer using a whole number.
654 Explanation: The nurse must add all the output volumes together: 450 ml + 125 ml + 35 ml + 32 ml + 12 ml = 654 ml. D5NS 1,000 ml is considered input, not output.
The hospital nurse is caring for a group of adult clients. For which client should the nurse most likely administer prophylactic anti-infectives? A client with colorectal cancer who is preoperative for a bowel resection A client with diabetic nephropathy who has recently begun dialysis A client who has hyperkalemia and who is receiving sodium polystyrene A client who is undergoing cardiac rehabilitation following a myocardial infarction
A client with colorectal cancer who is preoperative for a bowel resection Explanation: Abdominal surgery is a common indication for antibiotic prophylaxis, since these surgeries present a significant risk for infection. For this reason, a preoperative client would be more likely to need prophylaxis than a client who has had an MI, a client with renal failure or a client with an electrolyte imbalance.
A school nurse is trying to prevent poststreptococcal glomerulonephritis in children. What would be the best way to prevent this? Encourage the child to take all the antibiotics if diagnosed with strep throat. Tell parents to give ibuprofen if their child has a sore throat. All children in the child's class should be tested for strep throat if one child has a positive test. Prophylactic antibiotics after strep throat are important.
Encourage the child to take all the antibiotics if diagnosed with strep throat. Explanation: Encouraging the child to take all the antibiotics if diagnosed with strep throat is important. It is not necessary to test the people in the community with whom the child came in contact unless they are symptomatic. Ibuprofen does not cure strep throat, and strep infection is what usually causes poststreptococcal glomerulonephritis. Prophylactic antibiotics after a strep infection are not necessary.
After data collection on a client, the nurse suspects that the client has diarrhea. Which data collection finding, if observed by the nurse, would confirm the nurse's suspicion? Visible waves of abdominal peristalsis Hyperactive bowel sounds Increased anal area pigmentation Dry, hard stool
Hyperactive bowel sounds Explanation: Increased bowel motility, indicated by hyperactive bowel sounds, is commonly caused by diarrhea. Visible waves of abdominal peristalsis are commonly seen in intestinal obstruction. The anal area normally has increased pigmentation and some hair growth. Diarrhea stools are liquid in formation, whereas dry, hard stools are seen in constipation.
The nurse is planning care for a 4-day-old breastfed infant receiving phototherapy. What interventions and outcomes support a decrease in the serum bilirubin levels? Select all that apply. Infant breastfeeds every 2 to 3 hours. Urine output is 3 mL/kg/hr. Infant has one meconium stool per day. Infant breastfeeds 6 times per day. Infant has 3 to 4 seedy, yellow stools per day.
Infant breastfeeds every 2 to 3 hours. Urine output is 3 mL/kg/hr. Infant has 3 to 4 seedy, yellow stools per day. Explanation: Serum bilirubin levels can be decreased in infants who successfully breastfeed. The best way to judge successful breastfeeding and decrease bilirubin levels is to monitor intake and output and weight. Infants should breastfeed a minimum of 8 to 12 times per day for every 2 to 3 hours. A minimum acceptable urine output for an infant is 1 to 3 mL/kg/hr. Breastfed infants should have 2 to 3 seedy, yellow stools per day. One meconium stool per day is not enough, nor is breastfeeding 6 times per day.
A nurse is caring for a child with celiac disease. How would the nurse evaluate the effectiveness of nutritional therapy? Monitor vital signs every 4 hours. Monitor the appearance, size, and number of stools. Review blood urea nitrogen and serum creatinine levels. Record intake and output.
Monitor the appearance, size, and number of stools. Explanation: A gluten-free diet should eliminate fat, bulky, foul-smelling stools in a child with celiac disease. This finding indicates that the disease is controlled and the child is using nutrients effectively. Taking vital signs, reviewing blood urea nitrogen and serum creatinine levels, and recording intake and output don't indicate the effectiveness of nutritional therapy.
Because they strengthen the pelvic floor muscles, Kegel exercises are most likely to help which urinary problem? Overflow incontinence Urge incontinence Stress incontinence Mixed incontinence
Stress incontinence Explanation: Stress incontinence is commonly caused by weak pelvic floor muscles, which allow the angle between the bladder and the posterior proximal urethra to change so that the bladder and urethra are positioned for voiding when some activity increases intra-abdominal pressure. Overflow incontinence results when the bladder becomes distended and detrusor activity is absent. Urge incontinence is probably related to central nervous system control of bladder sensation and emptying or related to the smooth muscle of the bladder. Mixed incontinence, a combination of stress and urge incontinence, probably has more than one cause.
A client has an indwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification by the nurse? The catheter drainage bag is placed on the lower side of the wheelchair. The assistant brings a container to drain the urine from the bag. The catheter bag is placed on the client's lap for safe transport. The assistant checks to make sure the tubing is not kinked.
The catheter bag is placed on the client's lap for safe transport. Explanation: If the catheter bag were placed in the client's lap, the nurse would clarify to the assistant that the bag needs to be placed lower than the client's bladder so not to have backflow from the catheter tubing to the bladder. Placing the catheter on a lower portion of the wheelchair allows urine to flow through the tubing while minimizing risk of backflow. It is appropriate to drain the urine from the catheter bag before physical therapy and to make sure that there are no kinks in the tubing that would prevent urine flow to the drainage bag.
The nurse is inserting a urinary catheter into a 63-year-old male client and encounters resistance. What is the most likely cause of the resistance? The client has an enlarged prostate. The diameter of the catheter is too large. The nurse failed to deflate the retention balloon after pretesting it for integrity. The client has an occult abscess in the urethra.
The client has an enlarged prostate. Explanation: Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization. The client does not have an occult abscess in the urethra as the nurse was able to pass some of the catheter and then had resistance. The resistance is not caused by the balloon as this inflation had not occurred. The diameter of the catheter is not too large.
During a clinical assessment of a 68-year-old client who has suffered a head injury, a neurologist suspects that a client has a sustained damage to her vagus nerve (CN X). Which assessment finding is mostlikely to lead the physician to this conclusion? The client has difficulty swallowing and has had recent constipation and hypoactive bowel sounds. The client is unable to turn her head from side to side and her tongue is flaccid. The client has a unilateral facial droop, dry eyes, and decreased salivary production. The client is unable to perform any fine motor movements of her tongue.
The client has difficulty swallowing and has had recent constipation and hypoactive bowel sounds. Explanation: Dysphagia and impaired GI motility are associated with damage to the vagus nerve. Lateral movement of the head is mediated by CN XI. Facial droop and dry eyes are associated with CN VII, the facial nerve, while abnormal tongue movement is a result of damage to CN XII, the hypoglossal nerve.
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence? Stress Urge Overflow Functional
Urge Explanation: Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an overdistended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet.
A postmenopausal woman mentions experiencing stress incontinence. Which assessments should the nurse perform for this client related to stress incontinence? Select all that apply. Increased vaginal discharge Urinary tract infection Vaginitis Nocturia Dysmenorrhea
Urinary tract infection Vaginitis Nocturia Explanation: Stress incontinence is one of the complications associated with postmenopausal urogenital atrophy. Other associated problems include vaginal dryness (not increased discharge), urgency, nocturia, vaginitis, and urinary tract infection (UTI). Being postmenopausal, the woman would not experience dysmenorrhea, which is painful menstruation.
The nurse is caring for a client with an indwelling urinary catheter secondary to neurogenic bladder. The nurse completes a prescription to obtain a urine specimen from the catheter. After reviewing the image, what is the most accurate narrative note the nurse would document to demonstrate the steps to obtain the urine specimen were performed appropriately? A) Cleansed access port with warm soap and water, syringe attached and aspirated 10 mL of urine and placed in specimen container. B) Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. C) Obtained urine specimen from urinary drainage bag using a syringe, client expressed no discomfort during or after the procedure, verified prescription and cleansed access port. D) Gathered supplies, checked prescription, collected urine from access port and notified health care provider at the completion of the procedure.
Verified prescription, cleansed access port with antiseptic swab, aspirated urine from access port into sterile specimen container, client tolerated procedure well. Explanation: The nurse would ensure prescription is obtained, explain procedure to the client, use an antiseptic swab to cleanse the access port, then attach syringe and aspirate urine into the syringe. A specimen from the collecting receptacle (drainage bag) may not be fresh urine and could result in an inaccurate analysis. Always observe sterile technique while collecting a urine specimen from an indwelling catheter. Gather equipment, including a syringe, an antiseptic swab, a sterile specimen container, nonsterile gloves, and only tube tubing if needed; remember to unclamp the catheter after obtaining specimen to avoid reflux of urine into bladder.
Which clinical manifestations would tell a nurse that a client is having progressive decompensation related to obstruction of urinary outflow? Client complains of waking up several times in the night to void. When tested for residual urine volume, 1400 mL of urine is obtained when client is catheterized. Client states that he or she is incontinent. Client complains of urinary urgency.
When tested for residual urine volume, 1400 mL of urine is obtained when client is catheterized. Explanation: When compensatory mechanisms are no longer effective, signs of decompensation begin to appear. The period of detrusor muscle contraction becomes too short to expel the urine completely, and residual urine remains in the bladder. At this point, symptoms of obstruction become pronounced. These symptoms include frequency of urination, hesitancy, need to strain to initiate urination, a weak and small stream, and termination of the stream before the bladder is completely emptied. With progressive decompensation, the bladder may become severely overstretched with a residual urine volume of 1000 to 3000 mL. Urinary urgency is a compensatory mechanism. Incontinence may be caused by many different factors and does not indicate decompensation.
A client with Crohn's disease is to receive prednisone as part of the treatment plan. Which of the following instructions would be appropriate? "Take the drug on an empty stomach to avoid upsetting your stomach." "Once your symptoms improve, you can stop taking the drug." "Make sure to increase your salt intake to compensate for the loss of fluid." "Avoid contact with other people who might have an infection."
"Avoid contact with other people who might have an infection." Explanation: Clients taking corticosteroids may not experience a normal immune response to infection. The client needs to monitor himself or herself for signs and symptoms of infection and to avoid situations where they may be exposed to infection, such as others who might be ill. The drug should be taken with meals to decrease gastrointestinal irritation and should be withdrawn or tapered slowly to prevent Addisonian crisis. Clients also need to limit their sodium intake or follow a low-sodium diet to minimize water retention associated with this drug.
The nurse is calculating the urinary output for the infant. The infant's diaper weighed 40 g prior to placing the diaper on the infant. After removal of the wet diaper, the diaper weighed 75 g. How many milliliters of urine can the nurse document as urinary output? Record your answer using a whole number.
35 Explanation: The diaper must be weighed before being placed on the infant and after removal to determine urinary output. For each 1 gram of increased weight, this is the equivalent of 1 milliliter of fluid. 75 grams - 40 grams = 35 grams = 35 ml
Which procedure is a nonsurgical method of treatment for renal calculi (kidney stones)? Extracorporeal shock wave lithotripsy (ESWL) Percutaneous ureterolithotomy Percutaneous nephrolithotomy Retrograde ureteroscopy
Extracorporeal shock wave lithotripsy (ESWL) Explanation: ESWL is a nonsurgical treatment that uses sound waves, laser, or dry shock wave energy to break apart the stones. All of the other procedures are surgical in nature.
Which structure acts as an ultra-fine filter for all the blood that flows through it? Renal medulla Bowman's capsule Glomerulus Renal cortex
Glomerulus Explanation: The glomerulus acts as an ultra-fine filter for all the blood that flows into and through it.
The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following? Stoma ischemia Postoperative pneumonia Stoma retraction Peritonitis
Peritonitis Explanation: Clinical manifestations of peritonitis include abdominal pain and distention, absence of bowel sounds, nausea and vomiting, fever, changes in vital signs.
Which clinical manifestation would lead the nurse to suspect the client has malabsorption syndrome with a deficiency in fat absorption? Steatorrhea Abdominal cramping Dry eyes Glossitis
Steatorrhea Explanation: In malabsorption syndrome, there is loss of fat in the stools and failure to absorb the fat-soluble vitamins. This can result in weight loss, steatorrhea, and fat-soluble vitamin deficiency. Cramping is associated with water/electrolyte imbalances. Eye problems like dry eyes is due to malabsorption of vitamin A. Glossitis is associated with folic acid deficiency.
What best describes the structure of the kidneys? The renal pelvises drain urine into the ureters. The cortical nephrons concentrate urine. The renal arteries arise from the renal cortex. The glomerulus produces erythropoietin.
The renal pelvises drain urine into the ureters. Explanation: The renal pelvises drain the urine into the ureters. All nephrons filter and make urine, but only the medullary nephrons can concentrate or dilute urine. The renal arteries come directly off the aorta. Erythropoietin is produced by a small group of cells called the juxtaglomerular apparatus.
A group of students are reviewing information about disorders of the bladder and urethra. The students demonstrate understanding of the material when they identify which of the following as a voiding dysfunction? Cystitis Bladder stones Urinary retention Urethral stricture
Urinary retention Explanation: Urinary retention and urinary incontinence are voiding dysfunctions, temporary or permanent alterations in the ability to urinate normally. Cystitis is an infectious disorder. Bladder stones and urethral stricture are obstructive disorders.
The nurse is assigned to care for a patient in the oliguric phase of kidney failure. When does the nurse understand that oliguria is said to be present? When the urine output is less than 30 mL/h When the urine output is about 100 mL/h When the urine output is between 300 and 500 mL/h When the urine output is between 500 and 1,000 mL/h
When the urine output is less than 30 mL/h Explanation: Oliguria is defined as urine output <0.5 mL/kg/h
The nurse is caring for a client receiving an aminoglycoside (antibiotic) that can be nephrotoxic. Which will alert the nurse that the client may be experiencing nephrotoxicity? visual disturbances yellowing of the skin a decrease in urine output ringing noise in the ears
a decrease in urine output Explanation: Decreased urinary output, elevated blood urea nitrogen, increased serum creatinine, altered acid-base balance, and electrolyte imbalances can occur with nephrotoxicity. Ringing noise in the ears (tinnitus) is an indication of possible ototoxicity. Visual disturbances can suggest neurotoxicity, and yellowing of the skin (jaundice) is a sign of hepatotoxicity.
The nurse recognizes the most common cause of acute postinfectious glomerulonephritis as: a streptococcal infection 7 to 12 days prior to onset. prolonged blockage of the ureter with a stone. drug-induced damage to the renal glomeruli. uncontrolled diabetes with increased proteinuria.
a streptococcal infection 7 to 12 days prior to onset. Explanation: Acute postinfectious glomerulonephritis usually occurs after infection with certain strains of group A beta-hemolytic streptococci and is caused by deposition of immune complexes. It also may occur after infections by other organisms, including staphylococci and a number of viral agents, such as those responsible for mumps, measles, and chickenpox.
A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include: continuous inflow and outflow of irrigation solution. intermittent inflow and continuous outflow of irrigation solution. continuous inflow and intermittent outflow of irrigation solution. intermittent flow of irrigation solution and prevention of hemorrhage.
continuous inflow and outflow of irrigation solution. Explanation: When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution.
In the emergency department, a client arrives following a car accident. His pulse is 122; BP 88/60; respiration is 18 bpm. Urine output is 4 mL over the first hour on arrival. When in shock, this lower urine output is primarily due to: innervation of the sympathetic nervous system, causing constriction of the afferent arteriole. parasympathetic stimulation, causing the renal arteries to constrict in response to pain. obstruction in the glomerular capillaries due to overabundance of large molecules being released. high filtration rates in the glomerulus.
innervation of the sympathetic nervous system, causing constriction of the afferent arteriole. Explanation: During periods of strong sympathetic stimulation, such as shock, constriction of the afferent arteriole causes a marked decrease in renal blood flow, and thus glomerular filtration pressure. Consequently, urine output can fall almost to zero. The location of the glomerulus between two arterioles allows for maintenance of a high-pressure filtration system. The glomerular filtrate has a chemical composition similar to plasma, but contains almost no proteins because large molecules do not readily pass through the openings in the glomerular capillary wall.
A child is scheduled for a urea breath test. The nurse understands that this test is being performed for which reason? detect Helicobacter pylori evaluate gastric pH confirm pancreatitis determine esophageal contractility
detect Helicobacter pylori Explanation: Urea breath test is used to detect the presence of H. pylori in the exhaled breath. This test does not evaluate gastric pH. Serum amylase and lipase levels are used to confirm pancreatitis. Esophageal manometry is used to evaluate esophageal contractile activity and effectiveness.
The nurse is teaching a client how to collect a 24-hour urine specimen for creatinine clearance. Which directions should the nurse give the client? Select all that apply. "Save the first voiding and record the time." "Discard the first voiding and record the time." "Clean the perineal area before each voiding." "Refrigerate the urine sample or keep it on ice." "At the end of 24 hours, void and save the urine." "At the end of 24 hours, void and discard the urine."
"Discard the first voiding and record the time." "Refrigerate the urine sample or keep it on ice." "At the end of 24 hours, void and save the urine." Explanation: When collecting a 24-hour urine sample, the client should void, discard the urine, and record the time. This ensures that the client starts the collection period with an empty bladder. At the end of the 24-hour collection period, the client should void and save the urine. The first voiding is not used because it is not known how long the urine has been in the bladder. The urine sample should be refrigerated or kept on ice to keep it fresh. The perineum should be cleaned before obtaining a clean-catch urine specimen for culture and sensitivity. It is not necessary to clean the perineum for a 24-hour urine sample.
When a client reveals to a nurse during data collection that his stools are speckled, which appropriate question might the nurse ask the client? "Do you take any anticoagulants?" "Do you frequently consume red meats?" "Do you frequently take antacids?" "Do you drink lots of milk, but eat little meat?"
"Do you frequently take antacids?" Explanation: Medications and food may affect the color of stools. Antacids may cause speckling or a white discoloration. Anticoagulants may cause the stools to be light pink to red to almost black. Consuming large quantities of red meats may cause the stool to be almost black. Stools are light brown when consuming large amounts of milk and milk products along with a diet low in meats.
During the toddler years, the child attempts to become autonomous. Which statement by a 3-year-old toddler's caregiver indicates that the toddler is developing autonomy? "My toddler uses the potty chair and is dry all day long." "When my toddler falls down, they always wants me to pick them up." "My toddler has temper tantrums when we go to the store." "Every night my toddler follows the same routine at bedtime."
"My toddler uses the potty chair and is dry all day long." Explanation: During the toddler years, the toddler separates from his or her parents, recognizes one's own individuality and exerts autonomy. Being toilet trained is an example of the toddler developing autonomy or independence. Having temper tantrums is a normal response of the toddler as it is a way the toddler expresses frustration of being tired or not being able to accomplish a task. Having the parent pick up the child after the child falls is a security and emotional need. All children need this, so it is not indicative of toddlerhood or autonomy. Having the same routine for bedtime each night provides security but it does not demonstrate autonomy.
Which of the following diagnostic tests would the nurse expect to be ordered to determine the details of the arterial supply to the kidneys? Radiography Angiography Computed tomography (CT scan) Cystoscopy
Angiography Explanation: Angiography provides the details of the arterial supply to the kidneys, specifically the number and location of renal arteries. Radiography shows the size and position of the kidneys, ureters, and bladder. A CT scan is useful in identifying calculi, congenital abnormalities, obstruction, infections, and polycystic diseases. Cystoscopy is used for providing a visual examination of the internal bladder.
A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography? BUN and creatinine AST and ALT Hemoglobin and hematocrit Platelet count
BUN and creatinine Explanation: Angiography is done using fluorescein or indocyanine green as contrast agents. Fluorescein angiography is used to evaluate clinically significant macular edema, document macular capillary nonperfusion, and identify retinal and choroidal neovascularization (growth of abnormal new blood vessels) in age-related macular degeneration. It is an invasive procedure in which fluorescein dye is injected, usually into an antecubital vein. Prior to the angiography, the patient's blood urea nitrogen (BUN) and creatinine should be checked to ensure that the kidneys will excrete the contrast agent (Fischbach & Dunning, 2011).
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition? Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. BUN of 18 mg/dL. Serum creatinine of 1.2 mg/dL. Glomerular filtration rate (GFR) of 100 mL/min.
Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. Explanation: The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop.
The family asks the nurse what the usual treatment of focal segmental glomerulosclerosis entails. What is the nurse's bestresponse? Pain medications Antibiotics Antiviral medications Corticosteroids
Corticosteroids Explanation: The disorder usually is treated with corticosteroids. Although kidney transplantation is the preferred treatment for end-stage kidney disease, focal segmental glomerulonephritis occurs in half of these people. Pain medications may help relieve symptoms but will not treat the disease. Antivirals and antibiotics are not effective in FSGS.
A female client is diagnosed with recurrent urinary tract infections (UTIs) and the nurse is providing education about preventative methods. What information is important for the nurse to give to the client to prevent another UTI? Select all that apply. Dry the perineal area after urination or defecation from the back to the front. Take baths instead of showers. Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body.
Drink two 8-oz glasses (480 mL) of water before and after sexual intercourse and void immediately after intercourse. Wear underwear with a cotton crotch. Avoid clothing that is tight and restrictive on the lower half of the body. Explanation: Client education can help prevent UTI recurrence. Teaching the client about measures that promote health and decrease the severity and incidence of UTIs is a major nursing responsibility. The nurse should instruct the client to drink eight to ten 8-oz glasses (1,920 to 2,400 mL) of water daily, drink two 8-oz glasses (480 mL) of water before and after sexual intercourse, void immediately after sexual intercourse, wear underwear with a cotton crotch, and avoid clothing that is tight and restrictive on the lower half of the body. Instruction should include drying the perineal area after urination or defecation from the front to the back, or from the urethra toward the rectum, as well as taking showers instead of baths.
The nurse is teaching a client with multiple sclerosis about prevention of urinary tract infection (UTI) and renal calculi. Which nutrition recommendations by the nurse would be the most likely to reduce the risk of these conditions? Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. Drink a large amount of fluids, especially milk products, and eat a diet that includes multiple sources of vitamin D. Eat foods containing vitamins C, D, and E, and drink at least 2 L of fluid a day. Eat foods and ingest fluids that will cause the urine to be less acidic.
Increase fluids (2500 mL/day) and maintain urine acidity by drinking cranberry juice. Explanation: Increasing fluid intake will provide an internal irrigation and dilute the urine. This will lessen the probability of renal calculi forming. Cranberry juice is helpful in acidifying the urine and lessening the incidence of cystitis. Ingesting large amounts of milk and vitamin D will not decrease incidence of a UTI or renal calculi. Foods containing vitamins will not necessarily prevent these problems, nor will less acidic urine.
The nurse is planning care for a client with a urinary tract obstruction. The nurse includes assessment for which possible complication? Increased blood pressure Decreased blood pressure Diluted urine Polyuria
Increased blood pressure Explanation: Urinary tract obstruction can lead to hypertension related to increased renin secretion. The urine output would be decreased and not diluted.
The nurse is providing care to a client who has had a transurethral resection of the prostate. The client has a three-way catheter drainage system in place for continuous bladder irrigation. The nurse anticipates that the catheter may be removed when the urine appears as which of the following? Reddish-pink with numerous clots Dark amber with copious mucous Light yellow and clear Light pink with few red streaks
Light yellow and clear Explanation: Typically a three-way catheter drainage system is removed when the urine appears clear and amber (light yellow). Reddish-pink urine with clots usually occurs in the immediate postoperative period. Eventually the urine becomes light pink within 24 hours after surgery. Dark amber urine suggests concentrated urine commonly associated with dehydration.
The nurse is caring for a client with type 2 diabetes mellitus who complains of waking up with damp sheets. The client is not "wetting the bed" but fears urine is leaking when sleeping. Which assessment is the nurse's priority? Post-void residual urine assessment Urine for culture and sensitivity Examination of the urinary meatus and perineum. Review of recent blood glucose levels.
Post-void residual urine assessment Explanation: In this case, the client may be experiencing flaccid bladder related to peripheral diabetic neuropathy. This condition is associated with incomplete bladder emptying, which could be assessed using a post-void residual assessment. The client is not complaining of symptoms of a urinary tract infection, and having an infection would not lead to dribbling of urine. Peripheral neuropathies develop over long periods of time, so current trends of recent blood glucose levels will not offer relevant information. Physical assessment has limited use in determining causes of incontinence as most issues are not related to the gross anatomy of the client.
Sympathomimetics have which of the following effects on the body? Relaxation of bladder wall Decrease of heart rate Constriction of bronchioles Constriction of pupils
Relaxation of bladder wall Explanation: Sympathomimetics mimic the sympathetic nervous system, causing increased heart rate and contractility, dilation of bronchioles and pupils, and bladder wall relaxation.
A nurse is describing the renal system to a client with a kidney disorder. Which structure would the nurse identify as emptying into the ureters? Nephron Renal pelvis Parenchyma Glomerulus
Renal pelvis Explanation: The renal pelvis empties into the ureter which carries urine to the bladder for storage. The nephron consists of the glomerulus, afferent arteriole, efferent arteriole, Bowman's capsule, distal and proximal convoluted tubules, the loop of Henle, and collecting tubule. The nephron is located in the cortex and carries out the functions of the kidney. The parenchyma is made up of the cortex and medulla.
The nurse is preparing a client to receive a hypertonic enema solution. Into which position will the nurse place the client? prone supine semi-Fowler's Sims
Sims Explanation: Sims position is appropriate for a client who will receive this type of enema, as it promotes gravity distribution of the solution. Other choices are incorrect positions.
Diet therapy for clients diagnosed with irritable bowel syndrome (IBS) includes: caffeinated products. spicy foods. high-fiber diet. fluids with meals.
high-fiber diet. Explanation: A high-fiber diet is prescribed to help control constipation. Individuals experiencing diarrhea may be advised to eat a low-fiber diet. Foods that are possible irritants, such as caffeine, spicy foods, lactose, beans, fried foods, corn, wheat, and alcohol, should be avoided. Fluids should not be taken with meals because they cause abdominal distention.
A nurse who provides care on a pediatric unit of a hospital is aware that the potential for harm as a result of drug errors is higher among infants and children than adults. This fact is primarily due to: the inability of infants and children and describe symptoms of adverse drug reactions. increased body surface area relative to body volume in infants and children. increased heart rate and subsequently rapid drug distribution among infants and children. immature liver and kidney function in infants and children.
immature liver and kidney function in infants and children. Explanation: Children are more at risk of the deleterious effects of drug errors because they have not physiologically matured. Immature liver or renal function, for example, can increase the circulating level of a drug beyond what would be expected in adults. This characteristic supersedes differences in body surface area, cardiac function, and ability to verbalize discomfort.
Bladder retraining following removal of an indwelling catheter begins with encouraging the client to void immediately. advising the client to avoid urinating for at least 6 hours. performing straight catheterization after 4 hours. instructing the client to follow a 2- to 3-hour timed voiding schedule.
instructing the client to follow a 2- to 3-hour timed voiding schedule. Explanation: Immediately after the removal of the indwelling catheter, the client is placed on a timed voiding schedule, usually 2 to 3 hours, not 6 hours. At the given time interval, the client is instructed to void. Immediate voiding is not usually encouraged. If bladder ultrasound shows 100 mL or more of urine remaining in the bladder after voiding, straight catheterization may be performed to ensure complete bladder emptying.
The nurse measures a client's residual urine by catheterization after the client voids. Which condition would this test verify? urinary tract infection (UTI) urinary retention urinary incontinence urinary suppression
urinary retention Explanation: Urinary retention occurs when urine is produced normally but is not excreted completely from the bladder. Factors associated with urinary retention include medications, an enlarged prostate, or vaginal prolapse. Urinary incontinence is the inability for the client to control his urine. There are many different causes for urinary incontinence. Urinary tract infections are a leading cause of morbidity and health care expenditures in persons of all ages, accounting for up to 40% of infections reported by acute care hospitals. These infections can be of the upper or lower urinary system. Urinary retention is the inability to urinate. The causes of urinary retention are numerous.
A nurse is assessing a client on the second postpartum day. Upon palpation, the nurse discovers that the fundus is deviated to the right. To further investigate this finding, what should the nurse ask the client? "Are you having afterpains?" "Have you voided recently?" "When did you last change your perineal pad?" "Do you have any uterine tenderness?"
"Have you voided recently?" Explanation: The fundus should be palpated in the abdomen 2 days postpartum. The nurse should ask the client if she has voided recently because a full bladder may cause the fundus to deviate to the right or left. The nurse doesn't need to ask about afterpains because they aren't associated with fundal placement. The nurse should ask about the number of perineal pads used if she's assessing for uterine progression of hemorrhage. Asking about uterine tenderness would be appropriate when assessing for infection.
A nurse is conducting a class on various issues that might develop after going home with a new infant. After discussing how to care for hemorrhoids, the nurse understands that which statement by the class would indicate the need for more information? "I only eat a low-fiber diet." "I already have some pads with witch hazel at home." "My mom always used dibucaine." "Sitz baths worked the last time."
"I only eat a low-fiber diet." Explanation: Postpartum women are predisposed to hemorrhoid development. Nonpharmacologic measures to reduce the discomfort include ice packs, ice sitz baths, and application of cool witch hazel pads. Pharmacologic methods used include local anesthetics (dibucaine) or steroids. Prevention or correction of constipation and not straining during defecation will be helpful in reducing discomfort. Eating a high-fiber diet helps to eliminate constipation and encourages good bowel function.
A nurse is teaching a client scheduled for a cystoscopy about the procedure. Which statement made by the client verifies that the teaching has been successful? "The doctor will place a catheter into an artery in my groin and inject a dye that will visualize the blood supply to the kidneys." "The doctor will insert a lighted tube into the bladder, and little catheters will be inserted through the tube into my kidney." "The doctor will insert a lighted tube through my urethra into my bladder in order to inspect the inside of the bladder." "The doctor will inject a radioactive solution into my vein. The dye will distribute through my body and can be monitored by x-ray as it travels through my kidneys to my bladder."
"The doctor will insert a lighted tube through my urethra into my bladder in order to inspect the inside of the bladder." Explanation: Cystoscopy provides a means for direct visualization of the urethra, bladder, and ureteral orifices. It relies on the use of a cystoscope, an instrument with a lighted lens. The cystoscope is inserted through the urethra into the bladder. Biopsy specimens, lesions, small stones, and foreign bodies can be removed from the bladder.
A patient with a diagnosis of colon cancer has undergone a bowel resection with the creation of an ileostomy. The patient's ileostomy output has been unexpectedly high in the 2 days since surgery, and the patient's most recent blood work indicates a K+ level of 2.7 mEq/L. This potassium level should prompt the nurse to assess for which of the following physical manifestations? Confusion and decreased level of consciousness Shortness of breath, rales, and peripheral edema Dysphagia, tetany, and emotional lability Fatigue, cramps, and weakness
Fatigue, cramps, and weakness Explanation: A serum potassium level of 2.7 mEq/L constitutes hypokalemia. Manifestations of hypokalemia include fatigue, anorexia, nausea, vomiting, muscle weakness, leg cramps, decreased bowel motility, paresthesias (numbness and tingling), arrhythmias, and increased sensitivity to digitalis. Respiratory symptoms, dysphagia, and tetany are not typically associated with hypokalemia.
A client in her 39th week of gestation arrives at the maternity clinic stating that earlier in her pregnancy, she experienced shortness of breath. However, for the past few days, she has been able to breathe easily, but she has also begun to experience increased urinary frequency. A nurse is assigned to perform the physical examination of the client. Which observation is most likely? Fundal height has dropped since the last recording. Fundal height is at its highest level at the xiphoid process. The fundus is at the level of the umbilicus and measures 20 cm. The lower uterine segment and cervix have softened.
Fundal height has dropped since the last recording. Explanation: Between 38 and 40 weeks of gestation, the fundal height drops as the fetus begins to descend and engage into the pelvis. Because it pushes against the diaphragm, many women experience shortness of breath. By 40 weeks, the fetal head begins to descend and engage into the pelvis. Although breathing becomes easier because of this descent, the pressure on the urinary bladder now increases, and women experience urinary frequency. The fundus reaches its highest level at the xiphoid process at approximately 36, not 39, weeks. By 20 weeks' gestation, the fundus is at the level of the umbilicus and measures 20 cm. At between 6 and 8 weeks of gestation, the cervix begins to soften (Goodell sign) and the lower uterine segment softens (Hegar's sign).
The health care provider has prescribed an aminoglycoside (gentamicin) for a client. The nurse is aware that the client is at risk for: Nephrotoxic acute tubular necrosis Ischemic acute tubular necrosis Chronic kidney disease Postrenal failure
Nephrotoxic acute tubular necrosis Explanation: Pharmacologic agents that are directly toxic to the renal tubule include aminoglycosides (e.g., gentamicin), chemotherapeutic agents such as cisplatin and ifosfamide, and radiocontrast agents. Nephrotoxic agents cause tubular injury by inducing varying combinations of renal vasoconstriction, direct tubular damage, or intratubular obstruction. Postrenal failure results from obstruction of outflow of the kidneys. CKD and its treatment can interfere with the absorption, distribution, and elimination of drugs. Acute tubular necrosis (ATN) occurs most frequently in clients who have major trauma, severe hypovolemia, overwhelming sepsis, trauma, or burns.
Which measure included in the care plan for a client in the fourth stage of labor requires revision? Check vital signs and fundal checks every 15 minutes. Have the client spend time with the neonate to initiate breast-feeding. Obtain an order for catheterization to protect the bladder from trauma. Perform perineal assessments for swelling and bleeding.
Obtain an order for catheterization to protect the bladder from trauma. Explanation: While catheterization is done for a postpartum complication of urinary retention, it isn't routinely done to protect the bladder from trauma. The other options are appropriate measures to include in the care plan during the fourth stage of labor, which begins with placental expulsion and extends through the next 1 to 2 hours.
The nurse is caring for a 10-year-old boy with end-stage kidney disease (ESKD) with metabolic acidosis. What would the nurse expect to administer if ordered? Sodium bicarbonate tablets Ferrous sulfate Vitamin D Erythropoietin
Sodium bicarbonate tablets Explanation: Bicitra or sodium bicarbonate tablets are used for the correction of acidosis. Ferrous sulfate is used for the treatment of anemia. Vitamin D and calcium are used for the correction of hypocalcemia and hyperphosphatemia. Erythropoietin stimulates red blood cell growth.
Parathyroid hormone (PTH) has which effects on the kidney? Stimulation of calcium reabsorption and phosphate excretion Stimulation of phosphate reabsorption and calcium excretion Increased absorption of vitamin D and excretion of vitamin E Increased absorption of vitamin E and excretion of vitamin D
Stimulation of calcium reabsorption and phosphate excretion Explanation: PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D. PTH doesn't have a role in the metabolism of vitamin E.
The client had an ostomy created 3 days prior. The nurse is planning to teach the client how to empty the ostomy pouch. What is the besttime for the nurse to conduct the teaching? the time that the nurse and client mutually agree upon just prior to the end of the nurse's shift at the time the nurse perceives he or she will have time to conduct the teaching before the client's lunch
the time that the nurse and client mutually agree upon Explanation: The time to conduct the teaching should be mutually agreed upon by the nurse and client in order for the teaching to be most effective. Performing the teaching just prior to the end of the nurse's shift does not take into account when the client would feel most comfortable with the teaching. While it is important that the nurse has the time to conduct the teaching, it is also important that the client feels it is a good time for the teaching to occur. Conducting the teaching right before lunch does not take into account the client's feelings on when is a good time for the teaching to occur. Additionally, if the client is hungry, attention to the teaching might be hindered. Teaching is most effective when it occurs during a mutually agreed upon time.
