Med/Surg Final

Which statment is most appropriate for a nurse to tell a patient before insertion of the radioactive implant?

"Nurses will always be available, but they will spend only short periods of time at your bedside."

A home health patient undergoing radiation therapy says, "I feel so useless. I have no energy, no appetite and i fall asleep whenever i sit down." What is the nurse's most therapeutic response?

"Fatigue is an unfortunate side effect of radiation. It will improve when you finish treatment"

How many minutes of daily excercise does the America Cancer Society recommend as a prevention of Cancer?

20 minutes

Which of the following people should avoid visiting a patient being treated with internal radiation therapy?

A woman pregnant in the third trimester

According to evidence-based practice for patients undergoing stem cell transplants, which NANDA nursing diagnoses would be appropriate? Select all that apply. 1. Ineffective Coping 2. Fatigue 3. Interrupted Family Processes 4. Risk for Infection 5. Excess Fluid Imbalance

Correct Answer: 1,2,3,4 Rationale: Due to the long-term commitment (6-8 weeks) in isolation and the uncertainty of treatment's outcomes, coping mechanisms often become ineffective due to the variety of physical, mental, and financial issues that are faced during this life-threatening process. Role strain, depression, pain, loss of independence, and severe fatigue all contribute to difficulties in coping. Fatigue occurs with stem cell transplants from the complete bone marrow suppression, which causes anemia and decreased RBC to carry the oxygen needed for cellular functioning. Emotional stressors also create a fatigue while dealing with the entire treatment process. Major depression is not uncommon post-transplant. Family commitment and role changes are needed while hospitalized, since strict isolation occurs during the transplant treatment process. Children might not be allowed to visit, causing further separation by family members. Job roles (family dynamics) might be changed during hospitalization and recovery. Prior to transplant with stem cells, the patient receives total body chemotherapy, causing bone marrow suppression. Therefore, the WBCs are depleted prior to the transplant, and the ability to fight off an infection is decreased significantly, creating the need for strict isolation for the patient. With chemotherapy, there often is a tendency for nausea and vomiting, leading to fluid loss and not fluid retention. Therefore, the patient is more likely to have a "deficit" rather than an "excess" when receiving stem cell transplants. Steroid treatment can cause a fluid shift, but usually not an "excess fluid balance."

Which of these laboratory results would be most important for a nurse to monitor for a patient who has lower abdominal pain and urinary urgency? 1. serum creatinine 1.20 mg/dL 2. urine Osmolality 400 mOsm/kg H2O 3. BUN 30 mg/dL 4. urine culture 150,000 organisms/mL

Correct Answer: 4 Rationale 1: BUN and serum creatinine tests are use primarily to evlauate kidney function. Rationale 2: Urine osmolality is used to evaluate increaded and decreased urine output. Rationale 3: BUN and serum creatinine tests are use primarily to evlauate kidney function.

What should the home health nurse advise the patient who found a lump in her breats a week ago during breast self-examination?

Arrange for an examination by her physician

What happens during the process of immunosurveillane?

T cells recognizing and destroying the abnormal cell

The nurse instructs a patient who has been smoking for 5 years about the warning signs of cancer. The nurse tells him that one of cancer's seven warning signals include:

nagging cough or hoarseness

Nursing interventions for the nursing diagnosis of Imbalanced nutrition: less than body requirements would include all these except:

offer three regular meals of highly nutritious foods

When should the nurse schedule the oral administration of metoclopramide (Reglan)?

30 minutes before meals

Which of the following men should be highest priority for referral for a prostate-specific antigen (PSA)?

45 year old African American man

A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? a. "Participate in an exercise program to strengthen muscles." b. "Purchase a mattress that allows you to adjust the firmness." c. "Wear flat instead of high-heeled shoes to work each day." d. "Keep your weight within 20% of your ideal body weight."

ANS: A Exercise can strengthen back muscles, reducing the incidence of low back pain. The other options will not prevent low back pain.

After teaching a client with a spinal cord injury, the nurse assesses the client's understanding. Which client statement indicates a correct understanding of how to prevent respiratory problems at home? a. "I'll use my incentive spirometer every 2 hours while I'm awake." b. "I'll drink thinned fluids to prevent choking." c. "I'll take cough medicine to prevent excessive coughing." d. "I'll position myself on my right side so I don't aspirate."

ANS: A Often, the person with a spinal cord injury will have weak intercostal muscles and is at higher risk for developing atelectasis and stasis pneumonia. Using an incentive spirometer every 2 hours helps the client expand the lungs more fully and prevents atelectasis. Clients should drink fluids that they can tolerate; usually thick fluids are easier to tolerate. The client should be encouraged to cough and clear secretions. Clients should be placed in high-Fowler's position to prevent aspiration.

A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? a. Auscultated stridor b. Weak pedal pulses c. Difficulty swallowing d. Inability to shrug shoulders

ANS: A Postoperative swelling can narrow the trachea, cause a partial airway obstruction, and manifest as stridor. The client may also have trouble swallowing, but maintaining an airway takes priority. Weak pedal pulses and an inability to shrug the shoulders are not complications of this surgery.

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.

ANS: A, B, E A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

After teaching a client with a spinal cord tumor, the nurse assesses the client's understanding. Which statements by the client indicate a correct understanding of the teaching? (Select all that apply.) a. "Even though turning hurts, I will remind you to turn me every 2 hours." b. "Radiation therapy can shrink the tumor but also can cause more problems." c. "Surgery will be scheduled to remove the tumor and reverse my symptoms." d. "I put my affairs in order because this type of cancer is almost always fatal." e. "My family is moving my bedroom downstairs for when I am discharged home."

ANS: A, B, E Although surgery may relieve symptoms by reducing pressure on the spine and debulking the tumor, some motor and sensory deficits may remain. Spinal tumors usually cause disability but are not usually fatal. Radiation therapy is often used to shrink spinal tumors but can cause progressive spinal cord degeneration and neurologic deficits. The client should be turned every 2 hours to prevent skin breakdown and arrangements should be made at home so that the client can complete activities of daily living without needing to go up and down stairs.

A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) a. Heart rate of 34 beats/min b. Blood pressure of 185/65 mm Hg c. Urine output less than 30 mL/hr d. Decreased level of consciousness e. Increased oxygen saturation

ANS: A, C, D Neurogenic shock with acute spinal cord injury manifests with decreased oxygen saturation, symptomatic bradycardia, decreased level of consciousness, decreased urine output, and hypotension.

A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client's coping strategies? (Select all that apply.) a. Spiritual beliefs b. Level of pain c. Family support d. Level of independence e. Annual income f. Previous coping strategies

ANS: A, C, D, F Information about the client's preinjury psychosocial status, usual methods of coping with illness, difficult situations, and disappointments should be obtained. Determine the client's level of independence or dependence and his or her comfort level in discussing feelings and emotions with family members or close friends. Clients who are emotionally secure and have a positive self-image, a supportive family, and financial and job security often adapt to their injury. Information about the client's spiritual and religious beliefs or cultural background also assists the nurse in developing the plan of care. The other options do not supply as much information about coping.

A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask? a. "Are you taking a nonsteroidal anti-inflammatory drug?" b. "Do you have a mental health disorder?" c. "Are you able to swallow medications?" d. "Do you smoke cigarettes or any illegal drugs?"

ANS: B Clients who have a mental health or behavioral health problem should not take ziconotide. The other questions do not identify a contraindication for this medication.

A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? a. "Only lift items that are 10 pounds or less." b. "Wear your brace whenever you are out of bed." c. "You must remain in bed for 3 weeks after surgery." d. "You are prescribed medications to prevent rejection."

ANS: B Clients who undergo spinal fusion are fitted with a brace that they must wear throughout the healing process (usually 3 to 6 months) whenever they are out of bed. The client should not lift anything. The client does not need to remain in bed. Medications for rejection prevention are not necessary for this procedure.

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

ANS: B Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function. The other medications are inappropriate for this client.

A nurse assesses a client with early-onset multiple sclerosis (MS). Which clinical manifestation should the nurse expect to find? a. Hyperresponsive reflexes b. Excessive somnolence c. Nystagmus d. Heat intolerance

ANS: C Early signs and symptoms of MS include changes in motor skills, vision, and sensation. Hyperresponsive reflexes, excessive somnolence, and heat intolerance are later manifestations of MS.

A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client's discharge teaching? a. "Take warm baths to promote muscle relaxation." b. "Avoid crowds and people with colds." c. "Relying on a walker will weaken your gait." d. "Take prescribed medications when symptoms occur."

ANS: B The client should be taught to avoid people with any type of upper respiratory illness because these medications are immunosuppressive. Warm baths will exacerbate the client's symptoms. Assistive devices may be required for safe ambulation. Medication should be taken at all times and should not be stopped.

A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client's constipation? (Select all that apply.) a. Pour warm water over the perineum. b. Provide a diet high in fluids and fiber. c. Administer daily tap water enemas. d. Implement a consistent daily time for elimination. e. Massage the abdomen from left to right. f. Perform manual disimpaction.

ANS: B, D, F For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client that includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. If the client becomes impacted, the nurse would need to perform manual disimpaction. Pouring warm water over the perineum, administering daily enemas, and massaging the abdomen would not assist this client.

A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that an informed consent has been obtained before the test or procedure? a. Sensation measurement via the pinprick method b. Computed tomography of the cranial vault c. Lumbar puncture for cerebrospinal fluid sampling d. Venipuncture for autoantibody analysis

ANS: C A lumbar puncture is an invasive procedure with many potentially serious complications. The other assessments or tests are considered noninvasive and do not require an informed consent.

A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor? a. Peripheral edema b. Black tarry stools c. Bradycardia d. Nausea and vomiting

ANS: C Fingolimod (Gilenya) is an antineoplastic agent that can cause bradycardia, especially within the first 6 hours after administration. Peripheral edema, black and tarry stools, and nausea and vomiting are not adverse effects of fingolimod.

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

ANS: C Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.

A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? a. A 24-year-old female who is 25 weeks pregnant b. A 36-year-old male who uses ergonomic techniques c. A 45-year-old male with osteoarthritis d. A 53-year-old female who uses a walker

ANS: C Osteoarthritis causes changes to support structures, increasing the client's risk for low back pain. The other clients are not at high risk.

A nurse is caring for a client with paraplegia who is scheduled to participate in a rehabilitation program. The client states, "I do not understand the need for rehabilitation; the paralysis will not go away and it will not get better." How should the nurse respond? a. "If you don't want to participate in the rehabilitation program, I'll let the provider know." b. "Rehabilitation programs have helped many clients with your injury. You should give it a chance." c. "The rehabilitation program will teach you how to maintain the functional ability you have and prevent further disability." d. "When new discoveries are made regarding paraplegia, people in rehabilitation programs will benefit first."

ANS: C Participation in rehabilitation programs has many purposes, including prevention of disability, maintenance of functional ability, and restoration of function. The other responses do not meet this client's needs.

A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? a. Initiate oxygen via a nasal cannula. b. Place the client in a supine position. c. Palpate the bladder for distention. d. Administer a prescribed beta blocker

ANS: C The client is manifesting symptoms of autonomic dysreflexia. Common causes include bladder distention, tight clothing, increased room temperature, and fecal impaction. If persistent, the client could experience neurologic injury. Precipitating conditions should be eliminated and the physician notified. The other actions would not be appropriate.

A nurse cares for a client with a spinal cord injury. With which interdisciplinary team member should the nurse consult to assist the client with activities of daily living? a. Social worker b. Physical therapist c. Occupational therapist d. Case manager

ANS: C The occupational therapist instructs the client in the correct use of all adaptive equipment. In collaboration with the therapist, the nurse instructs family members or the caregiver about transfer skills, feeding, bathing, dressing, positioning, and skin care. The other team members are consulted to assist the client with unrelated issues.

A nurse assesses a client who is recovering from a lumbar laminectomy. Which complications should alert the nurse to urgently communicate with the health care provider? (Select all that apply.) a. Surgical discomfort b. Redness and itching at the incision site c. Incisional bulging d. Clear drainage on the dressing e. Sudden and severe headache

ANS: C, D, E Bulging at the incision site or clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. Loss of cerebral spinal fluid may cause a sudden and severe headache, which is also an emergency situation. Pain, redness, and itching at the site are normal.

After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.) a. "I will explore other ways besides intercourse to please my partner." b. "I will not be able to have an erection because of my injury." c. "Ejaculation may not be as predictable as before." d. "I may urinate with ejaculation but this will not cause infection." e. "I should be able to have an erection with stimulation."

ANS: C, D, E Men with injuries above T6 often are able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the client's partner will not get an infection.

The nurse is caring for a patient who states, "I need to micturate." The nurse's best response is which of the following? 1. "There is a restroom at the end of the hallway." 2. "Have you been taking your medication on a daily basis?" 3. "Do you have a supply of sterile catheters?" 4. "Do you have someone who can drive you home?"

Correct Answer: 1 Rationale: Micturation is the acting of urinating or voiding. The best response is to direct the patient to a restroom.

A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client's hips and sacrum. Which actions should the nurse take? (Select all that apply.) a. Apply a barrier cream to protect the skin from excoriation. b. Perform range-of-motion (ROM) exercises for the hip joint. c. Re-position the client off of the reddened areas. d. Get the client out of bed and into a chair once a day. e. Obtain a low-air-loss mattress to minimize pressure.

ANS: C, E Appropriate interventions to relieve pressure on these areas include frequent re-positioning and a low-air-loss mattress. Reddened areas should not be rubbed because this action could cause more extensive damage to the already fragile capillary system. Barrier cream will not protect the skin from pressure wounds. ROM exercises are used to prevent contractures. Sitting the client in a chair once a day will decrease the client's risk of respiratory complications but will not decrease pressure on the client's hips and sacrum.

A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? a. Sleepy but arouses to voice b. Dry and cracked oral mucosa c. Pain present in lower back d. Bladder palpated above pubis

ANS: D A distended bladder may indicate damage to the sacral spinal nerves. The other findings require the nurse to provide care but are not the priority or a complication of the procedure.

A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, "I do not want to be placed on a mechanical ventilator." How should the nurse respond? a. "You should discuss this with your family and health care provider." b. "Why are you afraid of being placed on a breathing machine?" c. "Using the incentive spirometer each hour will delay the need for a ventilator." d. "What would you like to be done if you begin to have difficulty breathing?"

ANS: D ALS is an adult-onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity, eventually leading to paralysis. Once muscles of breathing are involved, the client must indicate in the advance directive what is to be done when breathing is no longer possible without intervention. The other statements do not address the client's needs.

A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)? a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles

ANS: D In ALS, progressive muscle atrophy occurs until a flaccid quadriplegia develops. Eventually, the respiratory muscles are involved, which leads to respiratory compromise. Dysarthria, dysphagia, and muscle weakness are early clinical manifestations of ALS.

A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching? a. "Stroke the inner aspect of your thigh to initiate voiding." b. "Use a clean technique for intermittent catheterization." c. "Implement digital anal stimulation when your bladder is full." d. "Tighten your abdominal muscles to stimulate urine flow."

ANS: D In clients with lower motor neuron problems such as spinal cord injury, performing a Valsalva maneuver or tightening the abdominal muscles are interventions that can initiate voiding. Stroking the inner aspect of the thigh may initiate voiding in a client who has an upper motor neuron problem. Intermittent catheterization and digital anal stimulation do not initiate voiding or bladder control.

A nurse prepares a client for prescribed magnetic resonance imaging (MRI). Which action should the nurse implement prior to the test? a. Implement nothing by mouth (NPO) status for 8 hours. b. Withhold all daily medications until after the examination. c. Administer morphine sulfate to prevent claustrophobia during the test. d. Place the client in a gown that has cloth ties instead of metal snaps.

ANS: D Metal objects are a hazard because of the magnetic field used in the MRI procedure. Morphine sulfate is not administered to prevent claustrophobia; lorazepam (Ativan) or diazepam (Valium) may be used instead. The client does not need to be NPO, and daily medications do not need to be withheld prior to MRI.

A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)

ANS: D Methylprednisolone is the drug of choice for acute exacerbations of the disease. The other drugs are not used to treat acute exacerbations of MS. Interferon beta-1b is used to treat and control MS, decrease specific symptoms, and slow the progression of the disease. Baclofen and dantrolene sodium are prescribed to lessen muscle spasticity associated with MS.

An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? a. Assess level of consciousness. b. Obtain vital signs. c. Administer oxygen therapy. d. Evaluate respiratory status.

ANS: D The first priority for a client with a spinal cord injury is assessment of respiratory status and airway patency. Clients with cervical spine injuries are particularly prone to respiratory compromise and may even require intubation. The other assessments should be performed after airway and breathing are assessed.

Which of the following is a meal that would represent foods that help prevent cancer?

Broiled chicken, cabbage with onion and garlic, and soy milk

A nurse is caring for a patient who has a diagnosis of peritonitis related to a ruptured appendix. The patient states, "I hope I don't get a kidney infection from this with my kidneys being so close to my appendix. I had a kidney infection before and I felt terrible." Which explanation would be most appropriate for the nurse to give the patient? 1. "Your kidneys are located outside the peritoneum, the sack that encloses the appendix." 2. "Good thinking. Infections in the abdomen can spread to other organs." 3. "You need to speak with your primary healthcare provider about your concern." 4. "We can check your urine daily to assure the infection is not spreading."

Correct Answer: 1

A patient who is scheduled to have a renal ultrasound tells a nurse, "I am afraid I will not be able to stand the pain of this test." Which of these outcomes would be most appropriate for the nurse to establish with this patient? The patient will 1. explain the typical experience of a patient having a renal ultrasound. 2. discuss feelings associated with painful experiences. 3. explain pain medications available during this procedure. 4. discuss the typical experience of a patient using conscious sedation.

Correct Answer: 1 Rationale: A renal ultrasound is a noninvasive test conducted to detect renal or perirenal masses, identify obstructions, and diagnose renal cysts and solid masses. It is done by applying a conductive gel to the skin and placing a small external ultrasound probe on the patient's skin. Sound waves are recorded on a computer as they are reflected off tissues. There is no discomfort associated with the test and pain medications are not needed. When the patient understands the typical experience for a patient having this test, fears of a painful experience will be addressed and resolved.

A nurse is assessing a 68-year-old female patient who states, "I am having episodes of urinary incontinence." The nurse should recognize this statement as indicating which of the following? 1. an abnormal finding requiring further testing 2. an indication of the presence of a urinary infection 3. a normal outcome of the aging process 4. the result of having several children

Correct Answer: 1 Rationale: An abnormal finding requiring further testing is correct because incontinence is not a normal part of the aging process, and therefore will require further investigation to identify the cause. An indication of the presence of a urinary infection is incorrect because although frequency and urgency can be symptoms of a urinary tract infection, a culture and sensitivity test is necessary in order to determine infection. A normal outcome of the aging process and a result of having several children are incorrect because incontinence is not normal, and is it not necessarily the result of having had several children.

The nurse is providing preoperative teaching for a patient scheduled for a cystogram. The nurse knows follow-up is needed when the patient states, "After the procedure, I need to contact my primary healthcare provider if I experience 1. bloody urine." 2. low urine output." 3. abdominal pain." 4. chills or fever."

Correct Answer: 1 Rationale: Some blood is expected in the urine following the procedure. The nurse should provide more information regarding the monitoring of blood in the urine. The nurse should instruct the patient to immediately notify the physician if the urine remains bloody for more than three voidings after the procedure, or if bright bleeding develops. Low urine output, abdominal or flank pain, chills, or fever do not identify blood in the urine although these complications can occur.

A nurse is developing a postoperative plan of care for a patient who is scheduled to have a cystogram. Which of these outcomes should receive priority in the plan? The patient will be free from signs and symptoms of which of the following? 1. hemorrhage 2. bladder perforation 3. urinary retention 4. postprocedure pain

Correct Answer: 1 Rationale 1: Using the ABCs to prioritize patients' needs, hemorrhage relates to circulation and is a priority concern over bladder perforation, urinary retention, and postoperative pain, though all are important.

A nurse is advising a nursing student who is preparing a teaching presentation for fellow students regarding urinalysis. Which of these teaching points, if made by the student, requires intervention by the nurse? 1. Urine culture 150,000 organisms/mL. Female patients should separate the labia with one hand and clean the labia with the other, using sterile cotton swabs saturated with a cleansing solution, wiping back to front. 2. serum creatinine 1.20 mg/dL. 3. urine osmolality 400 mOsm/kg H2O. 4. blood urea nitrogen (BUN) 30 mg/dL.

Correct Answer: 1 Rationale 2: The other test results are within normal range. Rationale 3: The other test results are within normal range. Rationale 4: The other test results are within normal range.

The nurse is caring for a patient who states, "My urine has a red-tinged appearance." Which of these questions would be the most important for the nurse to ask this patient? 1. "What medications do you take?" 2. "Are you allergic to any food or drugs?" 3. "Do you wake up at night to void?" 4. "How many times a day do you usually void?" 5. "What medications do you take?"

Correct Answer: 1 Rationale: "What medications do you take?" is correct because several common medications can cause the urine to become red-tinged. Red-tinged urine that occurs in the absence of medications can indicate hematuria, and will need further investigation. Red-tinged urine is not related to allergies. "Do you wake up at night to void?" and "How many times a day do you usually void?" are both incorrect because these questions will elicit data regarding frequency of urination, not red-tinged urine.

Which of these outcomes would be most appropriate for a nurse to establish with a patient who has just voided and who is scheduled to have a portable ultrasonic bladder scan immediatly? The scan will indicate which of the following? 1. less than 100 mL of urine in the bladder 2. between 100 and 150 mL of urine in the bladder 3. between 150 and 200 mL of urine in the bladder 4. more than 200 mL of urine in the bladder

Correct Answer: 1 Rationale: A normal ultrasonic bladder scan finding is less than 100 mL for a residual voiding.

A nurse is teaching a nursing student about the effects of a sustained drop in systemic blood pressure on the juxtaglomerular cells of the distal tubules in the kidneys. The nurse knows teaching has been effective when the student states, "This juxtaglomerular cell response to low blood pressure is utilized with the medication 1. captopril (Capoten)." 2. digoxin (Lanoxin)." 3. furosemide (Lasix)." 4. adenosine (Adenocard)."

Correct Answer: 1 Rationale: A sustained drop in systemic blood pressure triggers the juxtaglomerular cells to release renin. Renin acts on a plasma globulin, angiotensinogen, to release angiotensin I, which is in turn converted to angiotensin II. As a vasoconstrictor, angiotensin II activates vascular smooth muscle throughout the body, causing systemic blood pressure to rise. Captopril (Capoten) is an ACE inhibitor, which blocks the conversion of angiotensin I to the vasodilator angiotensin II. The other drugs are not ACE inhibitors.

A nurse is reviewing laboratory data for a patient who had a voiding cystogram that revealed an urge to void at 100 mL. Which of these nursing diagnoses should receive priority for this patient? 1. Risk for Urge Urinary Incontinence 2. Risk for Impaired Skin Integrity 3. Self-Care Deficit 4. Risk for Urinary Retention

Correct Answer: 1 Rationale: A voiding cystogram is conducted to evaluate bladder capacity and neuromuscular functions of the bladder, urethral pressures, and causes of bladder dysfunction. A measured quantity of fluid is instilled into the bladder, and the filling capacity and voiding pressures are measured. Normal values: urine stream strong and uninterrupted, normal filling pattern, and sensation of fullness; bladder capacity: 300-600 mL; urge to void: >150 mL; fullness felt: 300 mL. A patient who has a sensation of an urge to void at 100 mL is at greatest Risk for Urge Urinary Incontinence. Risk for Impaired Skin Integrity, Self-Care Deficit, and Risk for Urinary Retention would not be appropriate diagnoses for the patient with these test results.

When assessing a patient who is scheduled to have a CT scan of the kidneys, which of these findings would prompt the nurse to notify the primary healthcare provider? 1. allergy to iodine and seafood 2. . urinary output of 1,200 mL in 24 hours 3. last bowel movement one day ago 4. height 5'8" and weight 160 pounds

Correct Answer: 1 Rationale: Allergy to iodine and seafood is correct because a CT scan of the kidneys requires the injection of a radiopaque dye that contains iodine. A patient who is allergic to iodine or seafood will be unable to have this test. Urinary output of 1,200 mL in 24 hours, last bowel movement one day ago, and height 5'8" and weight 160 pounds are all incorrect because these are all normal findings, and therefore do not require that the physician be notified.

A patient with an allergy to iodine is scheduled to have the following diagnostic tests. Which requires immediate nursing intervention? 1. renal angiogram 2. renal scan 3. voiding cystogram 4. portable ultrasonic bladder scan

Correct Answer: 1 Rationale: An angiogram includes the use of contrast dye, which often contains iodine. The nurse should contact the primary healthcare provider to report the iodine allergy. The other tests do not use contrast media.

A public health nurse is performing teaching for a patient who will be obtaining a sample of urine for a urinalysis at home. Which of these patient comments will cause the nurse to provide clarifying information? 1. "I will get the specimen as soon as I get home this evening." 2. "I won't touch the inside of the cup or lid." 3. "I will refrigerate the specimen until I bring it to the laboratory tomorrow." 4. "I will give the laboratory a list of the medications I am taking."

Correct Answer: 1 Rationale: An early morning specimen is preferred. The patient is bringing the specimen to the laboratory tomorrow, so an early morning specimen is possible and the most accurate and useful specimen. The other options are correct information.

A nursing student is assessing a patient who is reporting constant dull pain over the lower abdomen. The student inspects, palpates, and auscultates the patient's abdomen. After leaving the patient's room the nurse tells the student, "Your assessment findings may not be accurate because you 1. palpated prior to auscultating." 2. inspected prior to palpating." 3. inspected prior to auscultating." 4. auscultated after inspecting."

Correct Answer: 1 Rationale: Auscultate immediately after inspection because percussion or palpation may increase bowel motility and interfere with sound transmission during auscultation.

When preparing a patient for an intravenous pyelogram (IVP), the nurse reviews diagnostic data, noting all of the following. Which of these findings requires notification of the physician before proceeding with the test? 1. blood urea nitrogen (BUN) 55 mg/dLdl 2. serum creatinine 1.3 mg/dL 3. urine culture <10,000 organisms/mL 4. residual urine of 80 mL

Correct Answer: 1 Rationale: Blood urea nitrogen (BUN) 55 mg/dL is correct because this level is elevated, indicating that there might be a problem of renal function. The physician will need to be notified because an IVP involves the injection of dye that must eventually cleared by the kidney, and if there is already compromised renal function, the test may not be administered. Serum creatinine 1.3 mg/dL, urine culture <10,000 organisms/mL, and residual urine of 80 mL are all incorrect because these values are all within the normal range, and therefore will not require physician notification

All of the following diagnostic tests are ordered for a patient with renal disease. The nurse understands that which one of the following will be used in the evaluation of the patient's glomerular filtration rate (GFR)? 1. creatinine clearance 2. blood urea nitrogen (BUN) 3. intravenous pyelogram (IVP) 4. renal ultrasound

Correct Answer: 1 Rationale: Creatinine clearance is correct because this study (a 24-hour urine) measures the ability of the kidney to clear a given amount of creatinine out of the plasma within a given time period. Creatinine is a substance produced from the breakdown of muscle and is cleared by the kidney at a constant rate. This test is used to determine the glomerular filtration rate or the ability of the kidney to clear substances out of the plasma. Blood urea nitrogen (BUN) measures the amount of urea in the plasma and, although it is reflective of kidney function, it can be affected by both protein intake and fluid balance. Intravenous pyelogram (IVP) identifies the structures of the urinary system, not the function. Renal ultrasound identifies renal or perirenal masses or obstructions.

A nurse on the postoperative unit should assign which of these staff members to perform a follow-up assessment for a patient who has returned home after having an intravenous pyelogram 24 hours ago? 1. RN floating from the immunology unit 2. LPN floating from the nephrology unit 3. LPN floating from the pulmonology unit 4. RN floating from the orthopedic unit

Correct Answer: 1 Rationale: Delayed reactions to contrast dyes containing iodine can occur. The most appropriate staff member to follow up with the patient is the RN from the immunology unit. This RN will have extensive experience with hypersentitivity reactions and is best prepared to meet the needs of the patient. Prior to discharge the nurse should instruct the patient to contact the healthcare provider for any delayed reactions to the dye (breathing difficulty, rash, itching, rapid heartbeat).

A patient states, "I have a family history of both type 1 and type 2 diabetes mellitus. Before I decide to have children, I am going to speak with a healthcare professional who specializes in working with people with health problems that are passed from parent to child." Which of these statements would be the most appropriate for the nurse to record in the patient's medical record? "The patient has a future plan to discuss concerns about familial tendency for diabetes with 1. a genetic counselor." 2. a home health nurse." 3. an obstetrician." 4. a physical therapist."

Correct Answer: 1 Rationale: Genetic counselors specialize in working with families who have diseases associated with heredity. The other options are incorrect.

A nurse is caring for a patient who asks the nurse why females are more likely than males to contract bladder infections. The nurse knows teaching has been effective when the patient identifies which of the following as a female risk factor for bladder infections? 1. The urinary meatus is closer to the bladder than in most males. 2. The urinary meatus is farther from the anus than most males. 3. The pH of the female urethra is more conducive to infection. 4. Females urinate more frequently than males, increasing risk.

Correct Answer: 1 Rationale: In females, the urethra is approximately 1.5 inches (3 to 5 cm) long, and the urinary meatus is anterior to the vaginal orifice. In males, the urethra is approximately 8 inches (20 cm) long. The shorter distance of the female urethra creates a mechanism by which more females than males contract bladder infections. The female urinary meatus is closer, not farther from the anus than in most males, also increasing risk for bladder infections. The pH of the female urethra is not more conducive to infection. Frequent urination decreases the risk of bladder infection making this choice incorrect.

Because of normal changes due to aging, the nurse anticipates that a 75-year-old patient's serum creatinine level might be which of the following? 1. 0.3 mg/dL 2. 2.4 mg/dL 3. 4.8 mg/dL 4. 6.4 mg/dL

Correct Answer: 1 Rationale: Lower than normal is correct because serum creatinine level reflects the by-product of muscle breakdown, and an older adult with less muscle mass can be expected to have a lower-than-normal level. 0.5-1.5 mg/dL is the normal creatinine range for adults. Higher than normal, variable with fluid status, and within normal range are all incorrect because the question is asking for the expected change due to the aging process, and that is less muscle mass, and therefore less serum creatinine.

In formulating the teaching plan for a patient who is taking metformin (Glucophage), the nurse should include which of these priority instructions? Notify your healthcare provider if 1. you need a diagnostic test that uses iodinated contrast. 2. your urine becomes orange or red-tinted. 3. your urine becomes more concentrated. 4. you need an intermittent or indwelling urinary catheterization.

Correct Answer: 1 Rationale: Oral hypoglycemic agents are contraindicated for use with iodinated contrast, as the combination of the two can precipitate renal failure. Patients should be taught to inform all healthcare providers if they have a prescription for an oral hypoglycemic agent. Orange or red-tinted urine, concentrated urine, or needing urinary catheterizations have no interaction with metformin.

Which of these findings, if identified in an adult patient who is scheduled for an intravenous pyelogram, should a nurse report to the primary healthcare provider immediately? 1. serum osmolality of 1500 mOsm/kg/H2O 2. serum creatinine of 1.30 mg/dL 3. blood urea nitrogen of 20 mg/dL 4. hourly urine output of 45 mL/hour

Correct Answer: 1 Rationale: Prior to the IVP the nurse should assess renal and fluid status, including serum osmolality, creatinine, and blood urea nitrogen (BUN) levels. Notify the physician of any abnormal values. This patient's serum osmolality is elevated. Normal findings are 50-1200 mOsm/kg/H2O. Elevated serum osmolality may indicate a high-protein diet, SIADH, Addison's disease, dehydration, or hyperglycemia. The creatinine, BUN, and hourly urine output findings are within normal limits for this patient.

A nurse is teaching a nursing student about kidney function. The nurse states, "In healthy kidneys, almost all organic nutrients such as glucose and amino acids are reabsorbed." The nurse knows the student understands teaching when the student states, "Your comment means that 1. the nutrients move from blood to filtrate to blood, then back to the blood." 2. the nutrients move from filtrate to blood, then back to the filtrate." 3. the nutrients remain in the kidneys at all times." 4. the nutrients are large molecules and remain in the blood at all times."

Correct Answer: 1 Rationale: Reabsorption may be active or passive. Substances move from the blood into the filtrate, then are reclaimed into the blood.

A patient who has prescriptions for both an intravenous pyelogram and a barium enema tells the nurse, "I will schedule the intravenous pyelogram to be done before the barium enema." Which of these responses by the nurse is most appropriate? 1. "Please make your appointments, as you have indicated." 2. "Please clarify with your primary healthcare provider which should be completed first." 3. "Please reverse the order of your planned appointments." 4. "The order of the tests is irrelevant. You may change the order to meet your needs."

Correct Answer: 1 Rationale: Schedule an IVP prior to any ordered barium test or gallbladder studies using contrast material, as residual contrast material from the barium enema or gallbladder studies may interfere with the IVP results.

The nurse is reviewing teaching with a patient who has a prescription for an intravenous pyelogram. The nurse recognizes that further teaching is needed when the patient states, "I will 1. not drink any fluids for at least 12 hours before the procedure." 2. start the bowel prep with a suppository the night before the procedure" 3. take the prescribed laxative the morning of the procedure." 4. not eat solid food for at least 8 hours before the procedure."

Correct Answer: 1 Rationale: Tell the patient not to eat food for 8 to 12 hours prior to the test; clear liquids are allowed. Instruct the patient to complete ordered pretest bowel preparation, including prescribed laxative or cathartic the evening before the test, and an enema or suppository the morning of the test.

A nurse is advising a nursing student who is preparing a teaching presentation for fellow students regarding urinalysis. Which of these teaching points, if made by the student, requires intervention by the nurse? 1. Males patients should retract the foreskin and cleanse the glans with three cotton sponges saturated with cleansing solution, using a circular motion. 2. Female patients should separate the labia with one hand and clean the labia with the other, using sterile cotton swabs saturated with a cleansing solution, wiping back to front. 3. After cleansing, patients should start voiding and then begin to collect the specimen. 4. Patients should start taking prescribed antibiotics only after the specimen is collected.

Correct Answer: 1 Rationale: The female patient should cleanse the perineum with a front-to-back motion to avoid contaminating the urethral meatus with fecal bacteria. The other options are correct.

The nurse is caring for patient who has been diagnosed with an altered mycogenic mechanism of the renal blood vessels. The patient asks, "Why is it so important that I treat my hypertension and keep my blood pressure within normal limits?" The nurse's best response is which of the following? 1. "Your kidneys may have difficulty protecting themselves from high blood pressure." 2. "Your blood pressure medication is toxic to your kidneys in high doses." 3. "If not controlled, the condition will require an indwelling urinary catheter." 4. "High blood pressure increases your risk for kidney stones."

Correct Answer: 1 Rationale: The myogenic mechanism, which responds to pressure changes in the renal blood vessels, controls the diameter of the afferent arterioles to achieve autoregulation. An increase in systemic blood pressure causes the renal vessels to constrict, whereas a decrease in blood pressure causes the afferent arterioles to dilate. These changes adjust the glomerular hydrostatic pressure and, indirectly, maintain the GFR. An alteration in this system exposes the kidneys to pressures that are too high for proper long term kidney function. Option 2 does not address the patient's question. Option 3 and 4 are incorrect.

A 12-year-old patient who is scheduled to have a renal angiogram asks why the nurse has touched the patient's feet and marked an "X" on the top of both feet. Which of these responses would be most appropriate for the nurse to make? 1. "I feel your pulses there. I can check that the blood is flowing properly to your legs and feet." 2. "Are you afraid? Why do you ask?" 3. "It is a nursing thing. What is that game you are playing?" 4. "A needle is inserted in your femoral artery so the circulation to your extremity could be compromised during this test."

Correct Answer: 1 Rationale: The patient is 12 years old. Most 12-year-old patients have reached the formal operations stage of thinking and can think abstractly and reason logically. The correct option addresses the patient's question directly. Asking the patient a closed question about fear and then asking why the patient asks closes down communication and may make the patient defensive. Telling the patient "it is a nursing thing" and then changing the subject from the patient's question minimizes the patient's concern. Using medical terms with which the patient is likely not familiar also blocks communication. This option may alarm the patient unnecessarily.

A nurse is assessing a patient. Which of the following patient statements best alerts the nurse to the likelihood of the patient having a distended bladder? 1. "I am in pain and it is worse when I press on my abdomen." 2. "My back is killing me." 3. "It feels like someone is stabbing me in the abdomen with a knife." 4. "It hurt constantly with spasms once in a while."

Correct Answer: 1 Rationale: The patient with a distended bladder experiences constant pain increased by any pressure over the bladder. Kidney pain is experienced in the back and the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. Renal colic (pain in response to renal calculi moving through the ureter) is severe, sharp, stabbing, and excruciating; often it is felt in the flank, bladder, urethra, testes, or ovaries. Bladder and urethral pain is usually dull and continuous but may be experienced as spasms.

A nursing student asks all of the following questions when assessing a patient who is scheduled to have an MRI of the kidneys. Which of these questions would require the nurse to intervene? 1. "When did you last have anything to eat or drink?" 2. "Have you ever been treated for chest pain?" 3. "Do you have any tattoos?" 4. "Is there any possibility you could be pregnant?"

Correct Answer: 1 Rationale: There are no restrictions regarding food or fluids for this test. Patients with a history of chest pain should be asked if they have a prescription for transdermal nitroglycerin patches, which must be removed prior to the test. The nurse should assess for any metallic implants (such as pacemakers, clips on brain aneurysms, body piercings, tattoos, and shrapnel). If present, the nurse should notify the imaging physician. Ask if patient is pregnant; if so the test is not performed.

A patient has been given instruction about adult polycystic kidney disease (APKD). Which of these statements, if made by the patient, would indicate that the patient needs further instruction? Select all that apply. 1. "This disorder can be cured if I take my medication carefully." 2. "APKD is inherited from parent to child." 3. "The problem that causes this disease is in the cell chromosomes." 4. "Many fluid-filled sacks are found in the kidneys." 5. "This disorder can cause my kidneys to work poorly."

Correct Answer: 1 Rationale: There is no medication that can cure this disorder. Adult polycystic kidney disease (APKD) is linked to a familial chromosome 16 disorder. The disease is characterized by large cysts in one or both kidneys and a gradual loss of kidney tissue with resultant chronic renal failure.

The nurse is caring for a patient who sustained a fall with a fractured femur and was unable to summon help or receive healthcare treatment for 48 hours. On arrival at the emergency department, the patient's blood urea nitrogen level is 50 mg/dL. The serum creatinine level is 1.0 mg/dL. These findings would help substantiate a nursing diagnosis of which of the following? 1. Deficient Fluid Volume 2. Anxiety related to crisis 3. Acute Pain 4. Impaired Nutrition

Correct Answer: 1 Rationale: To assess if the patient's elevated blood urea nitrogen is caused by dehydration or renal failure, the nurse assesses the serum creatinine value. The patient's serum creatinine is normal, which does not indicate kidney failure. A nursing diagnosis of Deficient Fluid Volume is appropriate for this patient.

A nurse working in a postoperative unit is caring for a patient who states, "I voided a small amount of urine, but I feel as if I need to void more and am unable to do so." The patient receives a prescription for a post-voiding residual urine test. The nurse correctly prepares to perform the procedure by gathering supplies that include which of the following? 1. a urine collecting device and a straight urinary catheter 2. a urine collecting device and a voiding diary 3. an indwelling urinary catheter and an insertion kit 4. a peripheral IV insertion kit and a urine collecting device

Correct Answer: 1 Rationale: To evaluate the amount of urine in bladder post-voiding is correct. This diagnostic test is ordered to determine urinary retention or incomplete bladder emptying, which could be a consequence of the operative experience. To correctly perform the procedure, the nurse gathers a urinary collecting device and asks the patient to void. A straight urinary catheter is inserted and removed and the amount of urine obtained from the bladder is measured. Voiding diaries, indwelling urinary catheters, and peripheral IVs are not required for this procedure.

A nurse is reviewing the diagnostic results of renal testing for an 80-year-old patient and notes that the patient's findings include a decreased size of the renal cortex, atherosclerosis of the renal arteries, and hypoosmolality of urine. Which of these explanations would be most appropriate for the nurse to give the patient? 1. These are typical changes associated with aging. 2. These are signs of chronic renal failure. 3. These are signs of acute renal failure. 4. These are signs of a genetic renal disorder.

Correct Answer: 1 Rationale: Typical age-related changes of the renal system include a decreased size of the renal cortex, atherosclerosis of the renal arteries, and hypoosmolality. Some of these manifestations may be associated with acute or chronic renal failure or a genetic renal disorder. This triad in an 80-year-old patient is an expected finding.

Which of these assessments of an 86-year-old patient requires immediate nursing intervention? 1. reports of urinary incontinence 2. reports of urinary frequency 3. reports of urinary urgency 4. reports of nocturia

Correct Answer: 1 Rationale: Urinary incontinence is not a normal part of aging and requires immediate nursing intervention. Reports of urinary frequency, urgency, and nocturia are more common in older adults than in younger people. These may represent normal changes expected with aging.

The nurse assesses a patient admitted to the medical-surgical unit who has a diagnosis of type I diabetes mellitus. The nurse notes that the patient's urine is cloudy and foul-smelling. Which of the following diagnostic tests does the nurse anticipate will be ordered based on this finding? 1. urine culture and sensitivity (C&S) 2. blood urea nitrogen (BUN) 3. creatinine clearance 4. residual urine

Correct Answer: 1 Rationale: Urine culture and sensitivity (C&S) is correct because cloudy and foul-smelling urine indicates a urinary tract infection. The diagnostic test to identify the organism responsible is a urine C&S. Blood urea nitrogen (BUN) measures the amount of urea (end product of protein metabolism) in the blood plasma. It does not identify infection. Creatinine clearance is a 24-hour urine test used to identify renal function; it will not identify an infection. Residual urine measures the amount of urine left in the bladder after voiding, and does not identify an infection.

The nurse working on a nephrology unit is providing telephone triage to a patient who states, "I am worried that my child may be genetically at risk for kidney problems in adulthood." The nurse should recognize that which of these comments by the patient best indicates that the patient's child may be at future risk for manifesting a genetic kidney disorder? 1. "My mother had lots of cysts on her kidneys." 2. "I have a bladder infection at least once a year." 3. "The child's father has Parkinson's disease." 4. "My father had kidney cancer."

Correct Answer: 1 Rationale: When conducting a health assessment interview and physical assessment, it is important for the nurse to consider genetic influences on health. During the health assessment interview, ask about family members with health problems affecting kidney function, or of family members diagnosed with polycystic disease. A grandmother with polycystic kidney disease increases the grandchild's risk for having the disorder. A yearly bladder infection in a mother is not the most important indicator of a genetic kidney disorder. Parkinson's disease is not associated with kidney disease. Kidney cancer is not highly associated with heredity.

Which of these explanations would be most appropriate for a nurse to give to a patient who is scheduled to have a portable ultrasonic bladder scan to measure residual urine? 1. "You will have more than one reading taken." 2. "You will have an intermittent urinary catheter inserted and removed." 3. "You will have to delay the urge to void as long as possible." 4. "You will have the scan one hour after voiding in the toilet."

Correct Answer: 1 Rationale: When performing a portable ultrasonic bladder scan the nurse obtains several readings and uses the largest (the most accurate). The nurse should print the information, place it on the patient's chart, and document the residual urine amount. The patient is not asked to delay voiding. No catheterization is performed as part of this test. The scan is performed immediately after the patient voids.

A nurse observes a colleague including all of these measures when providing care to a patient who recently had a percutaneous renal biopsy. Which would require the nurse to intervene? Select all that apply. Standard Text: Select all that apply. 1. monitors vital signs every 15 minutes 2. applies pressure to site for 15 minutes after procedure 3. teaches patient to use aspirin for minor post procedure pain 4. teaches patient to increase oral fluid intake 5. teaches patient to report decreased urination

Correct Answer: 1,2 Rationale: The nurse holds pressure at the percutaneous site of a renal biopsy for 20 minutes after the procedure. The patient is at risk for bleeding and should not use aspirin as an over-the-counter pain reliever immediately after a renal biopsy, as it will promote bleeding. Options 3, 4, and 5 are all correct.

The nurse is reviewing the serum creatinine laboratory results for a group of patients. The nurse identifies which of the following patients as being at risk for having falsely elevated serum creatinine levels: A patient with a diagnosis of which of the following? (Select all that apply.) 1. rhinovirus taking 10,000 mg of vitamin C daily 2. Parkinson's disease and a prescription for methyldopa 3. bipolar disorder and a prescription for lithium carbonate 4. acne vulgaris and a prescription for tetracycline 5. insomnia taking over-the-counter melatonin

Correct Answer: 1,2,3

A nurse is performing discharge teaching with a patient who had a cystogram. The nurse should instruct the patient to use which of the following techniques to promote comfort? Select all that apply. 1. Take a sitz bath. 2. Increase oral fluid intake. 3. Take acetaminophen for minor pain. 4. Apply heat to the lower back. 5. Drink one ounce of brandy or rum with warm water.

Correct Answer: 1,2,3 Rationale: Appropriate techniques for relieving pain after a cystogram include taking a sitz bath, increasing oral fluid intake, and using over-the-counter analgesics that do not promote bleeding. Apply heat to the lower abdomen, not the lower back. Tell the patient to avoid alcoholic drinks for two days and that a slight burning sensation with voiding may occur for a day or two.

A nurse is teaching a patient about a voiding cystogram procedure. Which of these statements, if made by the patient, would indicate that the patient has the correct understanding of the instruction? Select all that apply. 1. "A urinary catheter will be placed in my bladder." 2. "My bladder will be filled with fluid" 3. "I will describe when my bladder feels full." 4. "A peripheral IV will be inserted in my arm." 5. "I will be sedated for the procedure."

Correct Answer: 1,2,3 Rationale: During this procedure a urinary catheter will be placed in the bladder, then the bladder will be filled and during filling the patient will be asked to describe the first urge to void, and the sensation of being unable to delay urination any longer. A peripheral IV is not needed for this procedure and the patient is not sedated as the patient must report when the sensation of bladder filling is occurring.

When assessing a patient who is scheduled for a cystogram and at risk for complications directly related to the procedure, a nurse should alert the primary healthcare provider if the patient has which of these clinical manifestations? Select all that apply. 1. cystitis 2. prostatitis 3. neuroleptic malignant syndrome 4. right-sided hemiplegia 5. chronic pain

Correct Answer: 1,2,3 Rationale: When caring for a patient undergoing a cystogram, the nurse will assess history of cystitis or prostatitis (these disorders could result in sepsis after the procedure), hypersensitivity to anesthetics, and urinary patterns (amount, color, odor). Right-sided hemiplegia and chronic pain are not issues for this patient.

The nurse is reviewing the laboratory results for a patient who has a prescription for an estimated glomerular filtration rate (EGFR). The nurse knows that which of the following factors may be utilized to determine the estimated glomerular filtration rate? Select all that apply. 1. serum creatinine 2. patient's age 3. patient's gender 4. patient's racial origin 5. serum blood urea nitrogen

Correct Answer: 1,2,3,4 Rationale: The EGFR is calculated based on the serum creatinine, age, gender, and (in some instances) racial origin. Serum blood urea nitrogen results is not utilized.

Using the TNM staging classification system, what does a tumor staged as T4N3M2 mean

Enlarging tumor, increasing lymph node involvement, and distant metastasis

A female patient, age 59, has lost 10 lb in the first 3 weeks of her chemotherapy and does not eat because nothing tastes good. What would be the appropriate nursing diagnosis for the plan of care?

Imbalanced nutrition: less than body requirments, related to anorexia

How would the nurse explain to the patient who is taking cyclophosphamide (Cytoxan), an alkylating agent, about how the medication works?

It interferes with DNA replication

After an elevation of his PSA, the patient has blood drawn for a CA-19-9. When he asks the nurses the purpose of this new test, what is the most appropriate response?

It tests for hepatobiliary cancer

The nurse is caring for a patient who is being treated for cancer of the cervix by a radioactive implant discovers that the applicator with radioactive material has become dislodged and is lying in the bed between the patient's legs. What should the nurse do?

Notify the charge nurse

What measures would the home health nurse, designing nursing interventions for a patient recieving external radiation treatments for a malignancy, recommend to protect the patient's skin?

Patting the skin dry after the bath

A patient, age 39, receiving chemotherapy for treatment of her cancer has a white blood cell count of 1600/mm3. This finding requires nursing interventions to provide which of the following?

Protection against infection

A male patient is undergoing external radiation therapy on an outpatient basis for treatment of Hodgkin disease. After 2 weeks of treatment, he tells the nurse that he is so tired he can hardly get out of bed in the morning. Which is an appropriate goal?

Take two rest periods during the day

A patient, age 63, has terminal cancer of the liver and is cared by his wife at home. His abdominal pain has become increasingly sever, and he now says it is intense most of the time. The nurse recognizes that teaching regarding pain management has been effective based on which measure implemented by this patient?

Taking analgesics around the clock on a regular schedule, using additional doses for breakthrough pain

The patient recieving radiation therapy complains of the conspicuous markings on the skin. What can the nurse explain about these marking?

They are gridlines for treatment and should be left on

A patient, age 56, has been advised that his prostate-specific antigen (PSA) level is elevated. The physician then performed a digital rectal examination (DRE). What should the next definitive diagnostic test be ?

Transrectal ultrasound

A patient has developed stomatitis from chemotherapy. What should the appropriate intervention for this condition include?

Using a soft toothbrush