NCLEX 10000 Genitourinary Disorders
When educating a female client with gonorrhea, the nurse should emphasize that for women gonorrhea: a) does not lead to serious complications. b) may not cause symptoms until serious complications occur. c) can be treated but not cured. d) is often marked by symptoms of dysuria or vaginal bleeding.
may not cause symptoms until serious complications occur. Correct Explanation: Many women do not seek treatment because they are unaware that they have gonorrhea. They may be symptom-free or have only very mild symptoms until the disease progresses to pelvic inflammatory disease
A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should assess the client for: a) respiratory paralysis. b) renal shutdown. c) seizures. d) cardiac arrest.
respiratory paralysis. Correct Explanation: If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside.
Which steps should a nurse follow to insert a straight urinary catheter? a) Put on gloves, prepare equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6″. b) Create a sterile field, drape the client, clean the meatus, and insert the catheter 6″. c) Prepare the client and equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows. d) Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows.
Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. Correct Explanation: Preparing the client and equipment, creating a sterile field, putting on gloves, cleaning the urinary meatus, and inserting the catheter until urine flows are all the vital steps for inserting a straight catheter.
The client with acute renal failure asks the nurse for a snack. Because the client's potassium level is elevated, which snack is most appropriate? a) a gelatin dessert b) yogurt c) an orange d) peanuts
a gelatin dessert Correct Explanation: Gelatin desserts contain little or no potassium and can be served to a client on a potassium-restricted diet. Foods high in potassium include bran and whole grains; most dried, raw, and frozen fruits and vegetables; most milk and milk products; chocolate, nuts, raisins, coconut, and strong brewed coffee.
Which nursing measure would most likely relieve postoperative gas pains after abdominal hysterectomy? a) offering the client a hot beverage b) applying a snugly fitting abdominal binder c) providing extra warmth d) helping the client walk
helping the client walk Correct Explanation: The discomfort associated with gas pains is likely to be relieved when the client ambulates. The gas will be more easily expelled with exercise. The anesthesia, analgesics, and immobility have altered normal peristalsis. Peristalsis will be stimulated by exercise.
The client with first-time bacterial cystitis is being treated with an antibiotic to be taken for 7 days. The nurse should instruct the client to: a) use condoms if having sex. b) notify the health care provider (HCP) when the urine is clear. c) limit fluids to 1,000 mL/day. d) take the entire prescription as ordered.
take the entire prescription as ordered. Correct Explanation: The client should take the prescription as ordered. The client should increase fluid intake to 3,000 mL/day to increase urination.
The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with which product? a) soap b) baking soda c) hydrogen peroxide d) alcohol
soap Correct Explanation: A reusable appliance should be routinely cleaned with soap and water. Other products are not necessary and may damage the appliance or be caustic to the client's skin.
The client asks the nurse, "How did I get this urinary tract infection?" The nurse should explain that in most instances, cystitis is caused by: a) congenital strictures in the urethra. b) urinary stasis in the urinary bladder. c) an infection elsewhere in the body. d) an ascending infection from the urethra.
an ascending infection from the urethra. Correct Explanation: Although various conditions may result in cystitis, the most common cause is an ascending infection from the urethra.
A nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 35 ml. Urine output that's less than 50 ml in 24 hours is known as: a) hematuria. b) polyuria. c) oliguria. d) anuria.
anuria. Explanation: Urine output less than 50 ml in 24 hours is called anuria. Urine output of less than 400 ml in 24 hours is called oliguria. Polyuria is excessive urination. Hematuria is the presence of blood in the urine
Which statements by a female client would indicate that she is at high risk for a recurrence of cystitis? a) "I can usually go 8 to 10 hours without needing to empty my bladder." b) "I wipe from front to back after voiding." c) "I take a tub bath every evening." d) "I work out by lifting weights 3 times a week."
"I can usually go 8 to 10 hours without needing to empty my bladder." Correct Explanation: Stasis of urine in the bladder is one of the chief causes of bladder infection, and a client who voids infrequently is at greater risk for reinfection.
A client is to take co-trimoxazole for a urinary tract infection. Which of the following statements indicates that the client knows how to correctly take the medication? a) "I should decrease my fluid intake to increase the concentration of the drug in my urine." b) "I will take the pills until my symptoms disappear." c) "I should take all the pills and then have the prescription renewed if I still have symptoms." d) "I will need to get a urine culture when I am finished taking the pills."
"I will need to get a urine culture when I am finished taking the pills." Correct Explanation: After completing the drug therapy, it will be necessary to obtain a urine culture to accurately determine the effectiveness of the antibiotic. It is possible for symptoms to be relieved, but bacteria to still be present in the urine. The client should complete the full course of prescribed therapy and not stop taking the drug because symptoms have disappeared
After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching? a) "I should eat foods from all the food groups." b) "I'll have to catheterize my pouch every 2 hours." c) "I'll need to drink at least eight glasses of water a day." d) "I'll have to wear an external collection pouch for the rest of my life."
"I'll have to wear an external collection pouch for the rest of my life." Correct Explanation: The client requires additional teaching if he states that he'll have to wear an external collection pouch for the rest of his life. An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch.
A client with a urinary tract infection is to take nitrofurantoin four times each day. The client asks the nurse, "What should I do if I forget a dose?" What should the nurse tell the client? a) "Take the prescribed dose as soon as you remember it, and if it is very close to the time for the next dose, delay that next dose." b) "Take a lot of water with a double amount of your prescribed dose." c) "Double the amount prescribed with your next dose." d) "You can wait and take the next dose when it is due."
"Take the prescribed dose as soon as you remember it, and if it is very close to the time for the next dose, delay that next dose." Explanation: Antibiotics have the maximum effect when the level of the medication in the blood is maintained. However, because nitrofurantoin is readily absorbed from the gastrointestinal tract and is primarily excreted in urine, toxicity may develop by doubling the dose.
A client with a history of renal calculi formation is being discharged after surgery to remove the calculus. What instructions should the nurse include in the client's discharge teaching plan? a) Eliminate dairy products from the diet. b) Increase daily fluid intake to at least 2 to 3 L. c) Strain urine at home regularly. d) Follow measures to alkalinize the urine.
Increase daily fluid intake to at least 2 to 3 L. Correct Explanation: A high daily fluid intake is essential for all clients who are at risk for calculi formation because it prevents urinary stasis and concentration, which can cause crystallization.
A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important? a) Increasing fluid intake to 3 L/day b) Using an indwelling urinary catheter to measure urine output accurately c) Encouraging the client to drink cranberry juice to acidify the urine d) Administering a sitz bath twice per day
Increasing fluid intake to 3 L/day Correct Explanation: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. Doing so helps empty the bladder of contaminated urine and prevents calculus formation.
After a radical prostatectomy for prostate cancer, a client has an indwelling catheter removed. The client then begins to have periods of incontinence. During the postoperative period, which intervention should be implemented first? a) Self-catheterization b) Artificial sphincter use c) Fluid restriction d) Kegel exercises
Kegel exercises Correct Explanation: Kegel exercises are noninvasive and are recommended as the initial intervention for incontinence.
A client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which nursing intervention is appropriate? a) Prepare to remove the catheter. b) Restrict fluids to prevent the client's bladder from becoming distended. c) Use sterile technique when irrigating the catheter. d) Tell the client to try to urinate around the catheter to remove blood clots.
Use sterile technique when irrigating the catheter. Correct Explanation: If the catheter is blocked by blood clots, it may be irrigated according to physician's orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection.
Which teaching approach for the client with chronic renal failure who has difficulty concentrating due to high uremia levels would be most appropriate? a) Conduct a one-on-one session with the client. b) Use video clips to reinforce the material as needed. c) Provide all needed teaching in one extended session. d) Validate the client's understanding of the material frequently.
Validate the client's understanding of the material frequently. Explanation: Uremia can cause decreased alertness, so the nurse needs to validate the client's comprehension frequently. Because the client's ability to concentrate is limited, short lessons are most effective
Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem? a) White blood cell (WBC) count of 20,000/mm3 (0.02 L) b) Hematocrit (HCT) of 35% c) Blood glucose level of 200 mg/dl (11.1 mmol/L) d) Potassium level of 3.5 mEq/L (3.5 mmol/L)
White blood cell (WBC) count of 20,000/mm3 (0.02 L) Correct Explanation: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client.
Which is likely to provide the most relief from the pain associated with renal colic? a) administering meperidine b) maintaining complete bed rest c) applying moist heat to the flank area d) encouraging high fluid intake
administering meperidine Correct Explanation: During episodes of renal colic, the pain is excruciating. It is necessary to administer opioid analgesics to control the pain. Application of heat, encouraging high fluid intake, and limitation of activity are important interventions, but they will not relieve the renal colic pain.
A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. The nurse should first: a) have the client use a sitz bath for 15 minutes. b) administer an oral analgesic. c) assess the patency of the urethral catheter. d) auscultate the abdomen for bowel sounds.
assess the patency of the urethral catheter. Correct Explanation: The lower abdominal pain is most likely caused by bladder spasms. A common cause of bladder spasms after TURP is blood clots obstructing the catheter; therefore, the nurse's first action should be to assess the patency of the catheter.
The nurse explains to the client the importance of drinking large quantities of fluid to prevent cystitis. The nurse should tell the client to drink: a) at least 3,000 mL of fluids daily. b) twice as much fluid as usual. c) at least 1,000 mL more than usual. d) as much water or juice as possible.
at least 3,000 mL of fluids daily. Correct Explanation: Instructions should be as specific as possible, and the nurse should avoid general statements such as "as much as possible." A specific goal is most useful.
A female client with gonorrhea informs the nurse that she has had sexual intercourse with her boyfriend and asks the nurse, "Would he have any symptoms?" The nurse responds that in men the symptoms of gonorrhea include: a) scrotal swelling. b) dysuria. c) urine retention. d) impotence.
dysuria. Explanation: Dysuria and a mucopurulent urethral discharge characterize gonorrhea in men. Gonococcal symptoms are so painful and bothersome for men that they usually seek treatment with the onset of symptoms.
A 24-year-old female client comes to an ambulatory care clinic in moderate distress with a probable diagnosis of acute cystitis. When obtaining the client's history, the nurse should ask the client if she has had: a) frequency and burning on urination. b) hematuria. c) flank pain and nausea. d) fever and chills.
frequency and burning on urination. Correct Explanation: The classic symptoms of cystitis are severe burning on urination, urgency, and frequent urination. Systemic symptoms, such as fever and nausea and vomiting, are more likely to accompany pyelonephritis than cystitis. Hematuria may occur, but it is not as common as frequency and burning.
A nurse is planning to administer a sodium polystyrene sulfonate enema to a client with a potassium level of 6.2 mEq/L. Correct administration and the effects of this enema should include having the client: a) retain the enema for 60 minutes to allow for glucose exchange; diarrhea isn't necessary to reduce the potassium level. b) retain the enema for 30 minutes to allow for glucose exchange; afterward, the client should have diarrhea. c) retain the enema for 60 minutes to allow for sodium exchange; diarrhea isn't necessary to reduce the potassium level. d) retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea.
retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. Correct Explanation: Sodium polystyrene sulfonate is a sodium-exchange resin. Thus, the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, sodium polystyrene sulfonate must be in contact with the bowel for at least 30 minutes. Sorbitol in the sodium polystyrene sulfonate enema causes diarrhea, which increases potassium loss and decreases the potential for sodium polystyrene sulfonate retention.
A sexually active male client has burning on urination and a milky discharge from the urethral meatus. What documentation should be included on the client's medical record? Select all that apply. a) history of unprotected sex (sex without a condom) b) names and phone numbers of all sexual contacts c) presence of any enlarged lymph nodes on examination d) allergies to any medications e) length of time since symptoms presented f) history of fever or chills
• length of time since symptoms presented • presence of any enlarged lymph nodes on examination • history of unprotected sex (sex without a condom) • history of fever or chills • allergies to any medications Correct Explanation: The client is suspected of having a sexually transmitted infection. Therefore, the client's sexual history, assessment, and examination must be documented, including symptoms (such as fever, chills, and enlarged glands) and their onset and duration. Allergies are critical to document for every client, but are especially noteworthy in this case because antibiotics will be prescribed. If a sexually transmitted infection is confirmed, sexual contacts need to be treated. To protect privacy, the names and phone numbers should never be placed in the medical record.
A nurse is collecting a health history on a client who's to undergo a renal angiography. Which statement by the client should be the priority for the nurse to address? a) "I'm allergic to shellfish." b) "I haven't eaten since midnight." c) "I've had diabetes for 4 years." d) "My physician diagnosed me with hypertension 3 months ago."
"I'm allergic to shellfish." Correct Explanation: An allergy to iodine, shellfish, or other seafood should immediately be investigated because the contrast agent used in the procedure may contain iodine, which can cause a severe allergic reaction. Although contrast agents should be used cautiously in clients with diabetes mellitus, investigating this isn't the nurse's priority if the client also has a shellfish allergy.
The nurse is caring for a client diagnosed with genitourinary tuberculosis (TB). Which statement, made by the client, about genitourinary TB demonstrates an understanding? a) "It isn't infectious, and I can't pass it from one person to another." b) "It's an early manifestation of an autoimmune disorder." c) "It's a late manifestation of respiratory tuberculosis." d) "I can't pass it sexually to my partner."
"It's a late manifestation of respiratory tuberculosis." Correct Explanation: Genitourinary TB is usually a late manifestation of respiratory TB and can occur if the disease spreads through the bloodstream from the lungs. Bacillus in the urine is infectious, and urine should be handled cautiously. A condom should be used during sex to prevent spread of the infection.
A client with diabetes mellitus has had declining renal function over the past several years. Which diet regimen should the nurse recommend to the client on days between dialysis? a) A low-protein diet with a prescribed amount of water b) A high-protein diet with a prescribed amount of water c) No protein in the diet and use of salt sparingly d) A low-protein diet with an unlimited amount of water
A low-protein diet with a prescribed amount of water Explanation: Although dialysis removes water, creatinine, and urea from the blood, the client's diet must still be monitored.
A nurse is caring for a client diagnosed with ovarian cancer. Diagnostic testing reveals that the cancer has spread outside the pelvis. The client has previously undergone a right oophorectomy and received chemotherapy. The client now wants palliative care instead of aggressive therapy. The nurse determines that the care plan's priority nursing diagnosis should be: a) Noncompliance. b) Impaired home maintenance. c) Knowledge deficit: Chemotherapy. d) Acute pain.
Acute pain. Correct Explanation: Palliative care for the client with advanced cancer includes pain management, emotional support, and comfort measures
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? a) Do not allow the client to ingest fluids. b) Request the central supply department to send supplies for straining urine. c) Administer an opioid analgesic as prescribed. d) Encourage the client to drink at least 500 mL of water each hour.
Administer an opioid analgesic as prescribed. Correct Explanation: If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention.
A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is focused on safe, effective care of this client? a) Consult the previous medical record from 2 years ago, and notify the health care provider (HCP) regarding medications that must be prescribed. b) Consult the pharmacist regarding identification of the medications. c) Show pictures to the client from the Physician's Desk Reference to identify the medications. d) Ask a family member to bring the medications from home in the original vials for proper identification and administration times.
Ask a family member to bring the medications from home in the original vials for proper identification and administration times. Correct Explanation: It is critical for medication safety to know the name, dosage, and times of administration of the medication taken at home. The family should bring the medication bottles to the hospital. The nurse should document the medication on the medical record from the bottles to ensure accuracy before the medication is prescribed and administered.
A client with acute pyelonephritis receives a prescription for co-trimoxazole P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the ordered regimen? a) Bacteria are absent on urine culture. b) Flank and abdominal discomfort decreases. c) The red blood cell (RBC) count is normal. d) Urine output increases to 2,000 ml/day.
Bacteria are absent on urine culture. Correct Explanation: Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect
The most significant sign of acute renal failure is: a) Elevated body temperature. b) Decreased urine output. c) Increased urine specific gravity. d) Increased blood pressure.
Decreased urine output. Correct Explanation: A sudden change in urine output is typical of acute renal failure. Most commonly, the initial change is greatly decreased urine output.
Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning? a) Diaphragms should not be used if the client develops acute cervicitis. b) Douching with an acidic solution after intercourse is recommended. c) The diaphragm should be washed in a weak solution of bleach and water. d) The diaphragm should be left in place for 2 hours after intercourse.
Diaphragms should not be used if the client develops acute cervicitis. Correct Explanation: The teaching plan should include a caution that a diaphragm should not be used if the client develops acute cervicitis, possibly aggravated by contact with the rubber of the diaphragm. Some studies have also associated diaphragm use with increased incidence of urinary tract infections.
When teaching the client with a urinary tract infection about taking a prescribed antibiotic for 7 days, the nurse should tell the client to report which symptoms to the health care provider (HCP)? Select all that apply. a) mild nausea b) cloudy urine for the first few days c) blood in the urine d) urinating every 3 to 4 hours e) fever above 100° F (37.8° C) f) rash
• rash • blood in the urine • fever above 100° F (37.8° C) Correct Explanation: The nurse should instruct the client to report signs of adverse reaction to the antibiotic or indications that the urinary tract infection is not clearing. Blood in the urine is not an expected outcome, rash is an adverse response to the antibiotic, and an elevated temperature indicates a persistent infection. These signs should be reported to the HCP
The nurse is teaching the client with an ileal conduit how to prevent a urinary tract infection. Which measure would be most effective? a) Maintain a daily fluid intake of 2,000 to 3,000 mL. b) Use sterile technique to change the appliance. c) Avoid people with respiratory tract infections. d) Irrigate the stoma daily.
Maintain a daily fluid intake of 2,000 to 3,000 mL. Correct Explanation: Maintaining a fluid intake of 2,000 to 3,000 mL/day is likely to be most effective in preventing urinary tract infection.
During the peritoneal dialysis, the nurse observes that the solution draining from the client's abdomen is consistently blood-tinged. The client has a permanent peritoneal catheter in place. The nurse should recognize that the bleeding: a) is expected with a permanent peritoneal catheter. b) can indicate kidney damage. c) is caused by too-rapid infusion of the dialysate. d) indicates abdominal blood vessel damage.
indicates abdominal blood vessel damage. Explanation: Because the client has a permanent catheter in place, blood-tinged drainage should not occur. Persistent blood-tinged drainage could indicate damage to the abdominal vessels, and the health care provider (HCP) should be notified.
A client scheduled for a vasectomy asks the nurse how soon after the procedure he can have sexual intercourse without using an alternative birth control method. How should the nurse respond? a) "You can safely have unprotected intercourse immediately after the procedure." b) "You can safely have unprotected intercourse after 6 to 10 ejaculations." c) "You can safely have unprotected intercourse as soon as discomfort from the procedure disappears." d) "You can safely have unprotected intercourse when your sperm count indicates sterilization."
"You can safely have unprotected intercourse when your sperm count indicates sterilization." Correct Explanation: After a vasectomy, sterilization isn't ensured until the client's sperm count measures zero. This usually requires 6 to 36 ejaculations
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client? a) Request the central supply department to send supplies for straining urine. b) Administer an opioid analgesic as prescribed. c) Encourage the client to drink at least 500 mL of water each hour. d) Do not allow the client to ingest fluids.
Administer an opioid analgesic as prescribed. Correct Explanation: If infection or blockage caused by calculi is present, a client can experience sudden severe pain in the flank area, known as renal colic. Pain from a kidney stone is considered an emergency situation and requires analgesic intervention.
A nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention? a) Foul-smelling discharge from the penis b) Rashes on the palms of the hands and soles of the feet c) Painful red papules on the shaft of the penis d) Cauliflower-like warts on the penis
Foul-smelling discharge from the penis Correct Explanation: Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination.
The client is on a fluid restriction of 500 ml/day plus replacement for urine output. Because the client's 24-hour urine output yesterday was 150 ml, the total fluid allotment for the next 24 hours is 650 ml. How should the nurses distribute this fluid over the next 24 hours? a) Given in small amounts throughout each shift. b) Given in its entirety in the morning to minimize the client's thirst during the rest of the 24 hour period. c) Given with meals, divided equally between breakfast and lunch. d) Supplemented with gelatin and ice cream.
Given in small amounts throughout each shift. Explanation: Thirst is a strong motivation to drink. Giving small amounts of fluid over all 3 shifts will help minimize thirst
Which nursing action is most appropriate for a client who has urge incontinence? a) Administer prophylactic antibiotics. b) Provide a bedside commode. c) Teach the client intermittent self-catheterization technique. d) Have the client urinate on a timed schedule.
Have the client urinate on a timed schedule. Explanation: Instructing the client to void at regularly scheduled intervals can help decrease the frequency of incontinence episodes.
When providing discharge teaching for a client with uric acid calculi, the nurse should include an instruction to avoid which type of diet? a) High purine b) High oxalate c) Low oxalate d) Low calcium
High purine Correct Explanation: To control uric acid calculi, the client should follow a low-purine diet, which excludes high-purine foods such as organ meats. The other diets do not control uric acid calculi.
A client is scheduled for a creatinine clearance test. What should the nurse do? a) Provide the client with a sterile urine collection container. b) Instruct the client to force fluids to 3,000 mL/day. c) Instruct the client about the need to collect urine for 24 hours. d) Prepare to insert an indwelling urethral catheter.
Instruct the client about the need to collect urine for 24 hours. Correct Explanation: A creatinine clearance test is a 24-hour urine test that measures the degree of protein breakdown in the body.
For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important? a) Promoting carbohydrate intake b) Providing pain-relief measures c) Limiting fluid intake d) Encouraging coughing and deep breathing
Limiting fluid intake Correct Explanation: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema
Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? a) Monitor patient blood pressure. b) Provide a high-protein, fluid-monitored diet. c) Encourage activity as tolerated. d) Place the client on a sheepskin, and monitor for increasing edema.
Monitor patient blood pressure. Explanation: Blood pressure control is a priority assessment in clients with poststreptococcal glomerulonephritis. The blood pressure can be increased for up to 6 weeks after treatment.
A male client informs the urology nurse that he is embarrassed because his wife rarely has time to reach sexual satisfaction during their encounters. He says he experiences orgasm as soon as he enters the wife's vagina. What is this condition best known as? a) Impotence. b) Retarded ejaculation. c) Premature ejaculation. d) Erectile failure.
Premature ejaculation. Correct Explanation: Premature ejaculation is when a man consistently achieves ejaculation or orgasm before or soon after entering the vagina.
A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? a) Blood pressure b) Temperature c) Respirations d) Pulse
Pulse Correct Explanation: An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. In addition to assessing the client's pulse, the nurse should place the client on a cardiac monitor because an arrythmia can occur suddenly.
A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which nursing action is most important at this time? a) Strain the urine carefully. b) Apply warm compresses to the flank area. c) Report hematuria to the health care provider (HCP). d) Administer meperidine every 3 hours.
Strain the urine carefully. Explanation: Intermittent pain that is less colicky indicates that the calculi may be moving along the urinary tract. Fluids should be encouraged to promote movement, and the urine should be strained to detect passage of the stone.
A client with bladder cancer had his bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? a) The pouch faceplate doesn't fit the stoma. b) A skin barrier was applied properly. c) Stoma dilation wasn't performed. d) The skin wasn't lubricated before the pouch was applied.
The pouch faceplate doesn't fit the stoma. Correct Explanation: If the pouch faceplate doesn't fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin.
A client who had a transurethral resection of the prostate (TURP) 1 day earlier has a three-way Foley catheter inserted for continuous bladder irrigation. Which of the following statements best explains why continuous irrigation is used after TURP? a) To control bleeding in the bladder. b) To prevent bladder distention. c) To keep the catheter free from clot obstruction. d) To instill antibiotics into the bladder.
To keep the catheter free from clot obstruction. Correct Explanation: Continuous irrigation, usually consisting of sterile normal saline, is used after TURP to keep blood clots from obstructing the catheter and impeding urine flow.
Which clinical finding should a nurse look for in a client with chronic renal failure? a) Metabolic alkalosis b) Polycythemia c) Hypotension d) Uremia
Uremia Correct Explanation: Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure.
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? a) Specific gravity of 1.03 b) Absence of protein c) Urine pH of 3.0 d) Absence of glucose
Urine pH of 3.0 Correct Explanation: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal and requires further investigation.
Which is likely to provide the most relief from the pain associated with renal colic? a) applying moist heat to the flank area b) maintaining complete bed rest c) encouraging high fluid intake d) administering meperidine
administering meperidine Correct Explanation: During episodes of renal colic, the pain is excruciating. It is necessary to administer opioid analgesics to control the pain.
The client with acute renal failure is recovering and asks the nurse, "Will my kidneys ever function normally again?" The nurse's response is based on knowledge that the client's renal status will most likely: a) improve only if the client receives a renal transplant. b) continue to improve over a period of weeks. c) result in end-stage renal failure. d) result in the need for permanent hemodialysis.
continue to improve over a period of weeks. Correct Explanation: The kidneys have a remarkable ability to recover from serious insult. Recovery may take 3 to 12 months.
A client with chronic renal failure is undergoing hemodialysis. Postdialysis, the client weighs 59 kg. The nurse should teach the client to: a) control the amount of protein intake to 59 to 70 g/day. b) increase fluid intake to 3,000 mL each day. c) increase sodium in the diet to 4 g/day. d) limit total calories consumed each day to 1,000.
control the amount of protein intake to 59 to 70 g/day. Correct Explanation: Hemodialysis clients have their protein requirements individually tailored according to their postdialysis weight. The protein requirement is 1.0 to 1.2 g/kg body weight per day. Hence, for a 59-kg weight, the amount of protein will be 59 to 70 g/day
A nurse is teaching a client how to prevent a vaginal infection. Which activity puts the client at risk for altering the normal pH of her vagina? a) consuming over four cups of coffee per day b) douching unless instructed to do so by the health care provider (HCP) c) using tampons during the menstrual cycle d) having sexual intercourse during the menstrual cycle
douching unless instructed to do so by the health care provider (HCP) Correct Explanation: Douching may disrupt the normal flora of the vaginal lactobacilli and change the pH, which could result in overgrowth of other bacteria.
A client is receiving peritoneal dialysis. While the dialysis solution is dwelling the client's abdomen, the nurse should: a) observe respiratory status. b) monitor electrolyte status. c) assess for urticaria. d) check capillary refill time.
observe respiratory status. Explanation: During dwell time, the dialysis solution is allowed to remain in the peritoneal cavity for the time prescribed by the health care provider (HCP) (usually 20 to 45 minutes). During this time, the nurse should monitor the client's respiratory status because the pressure of the dialysis solution on the diaphragm can create respiratory distress.
A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. The intended outcome of this diet is to: a) act as a diuretic. b) help maintain urine acidity. c) reduce demands on the liver. d) prevent the development of ketosis.
prevent the development of ketosis. Correct Explanation: High-carbohydrate foods meet the body's caloric needs during acute renal failure. Protein is limited because its breakdown may result in accumulation of toxic waste products. The main goal of nutritional therapy in acute renal failure is to decrease protein catabolism. Protein catabolism causes increased levels of urea, phosphate, and potassium. Carbohydrates provide energy and decrease the need for protein breakdown.
A client with chronic renal failure is receiving hemodialysis three times a week. To protect the fistula the nurse should: a) start a second IV in the arm with the fistula. b) maintain a pressure dressing on the shunt. c) report the loss of a thrill or bruit on the arm with the fistula. d) take the blood pressure in the arm with the fistula.
report the loss of a thrill or bruit on the arm with the fistula. Correct Explanation: The nurse must always auscultate for a bruit and palpate for a thrill in the arm with the fistula and promptly report the absence of either a thrill or bruit to the health care provider (HCP) as it indicates an occlusion.
