GNRS 556 - Med Surg II Study Guide for Test #3 (IN PROGRESS)

(Urinalysis (UA)) A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? A) Urine pH of 3.0 B) Absence of protein C) Specific gravity of 1.02 D) Absence of glucose

A - Urine pH of 3.0 Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation. Urine specific gravity normally ranges from 1.010 to 1.025, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber.

(Urinalysis (UA)) Select the results (in italics) that are normal in a urinalysis. A. pH 6 B. Specific gravity 1.015 C. Protein small D. Sugar negative E. Nitrate small F. Leukocyte esterase positive G. Bilirubin negative

A - pH 6 B - Specific gravity 1.015 D - Sugar negative G - Bilirubin negative Rationale: The abnormal values are indicative of a urinary tract infection. As a result of protein, nitrates, and leukoesterase in the urine, the nurse can expect the laboratory to analyze microscopic sediment including evaluating the sample for the presence of crystals, casts, WBCs, and RBCs.

(Laboratory testing) 16. A client with suspected diminished renal functioning has come to the outpatient clinic for an appointment. What laboratory test would be most accurate in assessing this client's renal reserve? A. 24-hour urine for creatinine clearance B. Serum blood urea nitrogen level C. Urine specific gravity D. Serum sodium level

ANS: A - 24 hour urine for creatinine clearance A 24-hour creatinine clearance test is necessary to detect changes in renal reserve. Creatinine clearance is a measure of the glomerular filtration rate. The ability of the glomeruli to act as a filter is decreased in renal disease.

(C. diff) A patient who is hospitalized with abdominal pain and watery, incontinent diarrhea is diagnosed with Clostridium difficile. In planning care for the patient, the nurse will A. order a diet with no dairy products for the patient. B. place the patient in a private room with contact isolation. C. explain to the patient why antibiotics are not being used. D. teach the patient about proper food handling and storage.

ANS: B Rationale: Because C. difficile is highly contagious, the patient should be placed in a private room and contact precautions should be used. There is no need to restrict dairy products for this type of diarrhea. Metronidazole (Flagyl) is frequently used to treat C. difficile. Improper food handling and storage do not cause C. difficile.

(BUN/Creatinine) The client has an elevated blood urea nitrogen (BUN) level and an increased ratio of blood urea nitrogen to creatinine. What is the nurse's interpretation of these laboratory results? A. The client probably has a urinary tract infection. B. The client may be over hydrated. C. The kidney may be hypo-perfused. D. The kidney may be damaged.

ANS: C - The kidney may be hypo-perfused When dehydration or renal hypo-perfusion exist, the BUN level rises more rapidly than the serum creatinine level, causing the ratio to be increased, even when no renal dysfunction is present.

(Laboratory testing) The nurse determines that a patient with AKI (acute kidney injury) is in the recovery phase when the patient experiences: A. A return to normal weight. B. A urine output of 3700 mL/day. C. Decreasing blood urea nitrogen (BUN) and creatinine levels. D. Decreasing sodium and potassium levels.

C. Decreasing blood urea nitrogen (BUN) and creatinine levels.

BUN/Creatinine Ratio

An increased ratio may be due to conditions that decrease blood flow to kidneys (e.g. heart failure, dehydration), GI bleeding, or increased dietary protein. A decreased ration may occur with liver disease and malnutrition. Reference interval: 12:1 to 20:1

(Urinalysis (UA)) The female client's urinalysis shows all the following characteristics. Which should the nurse document as abnormal? A. pH 5.6 B. Ketone bodies present C. Specific gravity is 1.030 D. Two white blood cells per high-power field ANS:

B - Ketone bodies present Ketone bodies are byproducts of incomplete metabolism of fatty acids. Normally, there are no ketones in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy.

(BUN) A patient with an elevated blood urea nitrogen (BUN): A. Has decreased urea in the urine. B. May have nonrenal tissue destruction. C. Definitely has impaired renal function D. Will always have a rise in serum creatinine.

B. May have non-renal tissue destruction.

(Urinalysis (UA)) When is the best time for nurse to collect specimen for urinalysis, how should it be collected, and what is the time frame for testing after the sample is collected?

Collect in the morning Clean catch specimen collection - before collecting, wash perineal area Ensure specimen is examined within 1 hour of urinating.

Urine Culture Normal + abnormal values for bladder and urethra Collection regulations

Confirms suspected urinary tract infection and identifies causative organisms. Normally there are no organisms in bladder, and there are <10 to the 3rd power organisms/mL in the urethra as a part of normal urethral flora. > 10 to the 3rd - 4th power organisms/mL is usually not diagnostic for infection, but tests may have to be repeated. >10 to the 5th power organisms/mL indicates infection Sterile container for collection of urine. Touch only outside of container. For women, separate labia with one hand and clean meatus with other hand, using at least three sponges in a front to back motion. For men, retract foreskin if present and cleanse glans with at least 3 cleansing sponges. After cleaning, instruct patient to start urinating and then after initial stream, begin voiding in the sterile container. The initial voided urine flushes out most contaminants in urethra and perineal area. Catheterization may be needed if patient is unable to cooperate with procedure.

Creatinine Creatinine Clearance (urinary study) Creatinine (blood)

Creatinine Clearance (urinary study): waste product of protein breakdown. Clearance by creatinine by kidney approximates the GFR. Collect 24-hour urine specimen. Discard first urination when test is started. Save urine from all subsequent urinations for 24 hour. Instruct patient to urinate at end of 24 hour and add specimen to collection. Ensure that serum creatinine is determined during 24 hour period. Creatinine (blood): more reliable than BUN as a determinant of renal function. Creatinine is an end product of muscle and protein metabolism and is released at a constant rate. Reference interval for blood creatinine test: 0.6-1.3 mg/dL (53-115 micr mol/L)

(Laboratory testing) The test that is most specific for renal function is the: A. Renal scan. B. Serum creatinine (blood) C. BUN D. Creatinine clearance (urine)

D. Creatinine clearance

(Laboratory testing) RIFLE defines three stages of AKI based on changes in: A. Blood pressure and urine osmolality. B. Fractional excretion of urinary sodium. C. Estimation of GFR with the MDRD equation. D. Serum creatinine or urine output from baseline.

D. Serum creatinine or urine output from baseline.

Clostridium difficile (C. diff)

Health-care associated infection. Spores can survive 70 days on objects (including commodes, telephones, thermometers, bedside tables, and floors. C. diff can be transmitted from patient to patient by health care workers who do not adhere to infection control precautions. Treatment: stopping antibiotics and starting metronidazole (Flagyl) or vancomycin (Vancocin). Metronidazole is the first line of treatment in mild disease because of concerns of the development of VRE (vancomycin resistant enterococcus). Recovery rates are substantially better with vancomycin, it is preferred for serious infections. Recurrent C. diff infection occurs in 20% of patients, and the probability of recurrence rises with each subsequent infection. Feces transplatation is under investigation as a therapeutic option for patients with recurrent and resistant C. diff (healthy persons' feces are inserted into the GI tract using an enema or nasogastric tube, or during colonoscopy).

Blood Urea Nitrogen (BUN) Normal values Clinical use + interpretation

Reference interval: 6-20 mg/dL (2.1-7.1 mmol/L) Used to detect renal problems. Concentration of urea in blood is regulated by rate at which kidney excretes urea. When interpreting BUN, be aware that non-renal factors may cause increase (e.g. rapid cell destruction from infections, fever, GI bleeding, trauma, athletic activity, and excessive muscle breakdown, corticosteroid therapy)

Urinalysis (UA) Normal Values Color Odor Protein Glucose Ketones Bilirubin Specific Gravity Osmolality pH RBCs WBCs Casts

Urinalysis is used for a general examination of urine to establish baseline information or provide data to establish a tentative diagnosis and determine whether further studies are needed. From Table 45-9 Color - amber yellow, clear (not cloudy) Odor - aromatic (no ammonia like odor) Protein - Random protein (dipstick): 0 - trace 24 hr protein (quantitative): <150 mg/day Glucose - None Ketones - None Bilirubin - None Specific Gravity - 1.003 - 1.030 Osmolality - 300-1300 mOsm/kg pH - 4.0-8.0 (average 6.0) RBCs - 0-4/hpf WBCs - 0-5/hpf Casts - None