Renal NCLEX questions

A hemodialysis client with a left arm fistula is at risk for arterial syndrome. The nurse monitors this client for which signs/symptoms of this disorder? 1. edema and purpura of the left arm 2. warmth, redness, and pain in the left hand 3. aching pain, pallor, and edema of the left arm 4. pallor, diminished pulse, and pain in the left hand

4. pallor, diminished pulse, and pain in the left hand

A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? 1. hematuria and pyuria 2. dysuria and proteinuria 3. hematuria and urgency 4. dysuria and penile discharge

4. dysuria and penile discharge

The nurse is reviewing the medical record of a client with a diagnosis of pyelinephritis. Which disorder noted on the clients record should the nurse identify as a risk factor of this diagnosis? 1. hypoglycemia 2. diabetes mellitus 3. coronary artery disease 4. orthostatic hypotension

2. diabetes mellitus

The nurse is inspecting the stoma of a client after creation of an ureterostomy. Which appearance should the nurse expect to note?

A red and moist stoma. After ureterostomy, the stoma should be red and moist. A pale stoma may indicate an inadequate amount of vascular supply, and a dry stoma may indicate a body fluid deficit. Any sign of darkness or duskiness in the stoma may mean a loss of vascular supply and must be corrected immediately, or necrosis can occur.

An alkaline-ash diet is prescribed for a client with renal calculi. Which diet menu does the nurse advise the client to select? Chicken, rice, and cranberries A spinach salad, milk, and a banana Peanut butter sandwich, milk, and prunes Pasta with shrimp, tossed salad, and a plum

A spinach salad, milk, and a banana In an alkaline-ash diet, all fruits are allowed except cranberries, prunes, and plums.

The nurse is reinforcing dietary instructions to a client with renal calculi who must learn to eat an alkaline-ash diet. The nurse determines that the client has properly understood the information presented if the client chooses which selection from a diet menu?

A spinach salad, milk, and a banana In an alkaline-ash diet, all fruits are allowed except cranberries, prunes, and plums.

The nurse is caring for a client who had a renal biopsy. Which interventions should the nurse include in the plan of care for the client after this procedure? Select all that apply. Restricting fluids during the first 24 hours Administering pain medication as prescribed Monitoring vital signs and the puncture site frequently Testing serial urine samples with dipsticks for occult blood Ambulating the client in the room and hall for short distances

Administering pain medication as prescribed. Monitoring vital signs and the puncture site frequently Testing serial urine samples with dipsticks for occult blood

The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? Select all that apply. Bed rest Sitz bath Antibiotics Heating pad Scrotal elevation

Bed rest Sitz bath Antibiotic Common interventions used in the treatment of epididymitis include bed rest, the elevation of the scrotum, ice packs, sitz baths, analgesics, and antibiotics

The nurse suspects the client has a urinary tract infection (UTI). Which signs/symptoms suggest a UTI? Select all that apply. Dysuria Hematuria Frequency Flank pain Polydipsia Cloudy urine

Dysuria Hematuria Frequency Flank pain Cloudy urine.

A client with acute kidney injury secondary to heart failure develops fluid volume excess. Which signs and symptoms should the nurse expect to see? Select all that apply. Weak pulse Weight gain Decreased hematocrit Distended jugular veins Decreased breath sounds on auscultation Decreased specific gravity with high volume

Weight gain Decreased hematocrit Distended jugular veins Decreased specific gravity with high volume

Aluminum hydroxide is prescribed for the client with chronic kidney disease (CKD). When should the nurse instruct the client to take this medication? With meals At bedtime On an empty stomach In the morning on arising

With meals The client with chronic kidney disease who is receiving aluminum hydroxide should take the medication with meals. The phosphate-binding effect is best when it is taken with food. If tablets are used, they should be chewed well before swallowing.

A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The nurse appropriately asks which question first? "Have you had any abdominal discomfort?" "Have you had any recurring bouts of diarrhea?" "Have you experienced any constipation recently?" "Have you had an increased amount of flatulence?"

"Have you experienced any constipation recently?" Reduced outflow from the dialysis catheter may be due to the catheter position, infection, or constipation. Constipation may contribute to a reduced outflow because peristalsis seems to aid in drainage.

Which statements indicate an understanding of the necessary dietary modifications of a client diagnosed with chronic kidney disease? Select all that apply. "I should avoid coffee; tea is preferable." "I should avoid eggs; a bagel is preferable." "I should avoid salt; soy sauce is preferable." "I should avoid salt; salt substitutes are preferable." "I should consume approximately 40 g of protein daily." "I should avoid carbonated sodas; milk is preferable."

"I should avoid eggs, and a bagel is preferable." "I should consume approximately 40 g of protein daily." Protein restriction is necessary in clients with chronic kidney disease because urea nitrogen and creatinine are the end products of protein metabolism, and clients with renal failure cannot excrete these waste products.

The nurse provides home care instructions to a client undergoing hemodialysis with regard to care of an arteriovenous (AV) fistula. Which statement by the client indicates an understanding of the instructions? "I should check the fistula every day by feeling it for a vibration." "I am glad that the laboratory will be able to draw my blood from the fistula." "I should wear a shirt with tight arms to provide some compression on the fistula." "I should check my blood pressure in the arm where I have my fistula every week."

"I should check the fistula every day by feeling it for a vibration." The client is instructed to monitor fistula patency daily by palpating for a vibration, known as a thrill. The client is instructed to avoid compressing the fistula with tight clothing or when sleeping and that blood pressure measurements and blood draws should not be performed on the arm with the fistula.

The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented? SELECT ALL THAT APPLY 1. bed rest 2. sitz bath 3. antibiotics 4. heating pad 5. scrotal elevation

1. bed rest 2. sitz bath 3. antibiotics 5. scrotal elevation

After a renal biopsy, the client complains of pain at the biopsy site that radiates to the front of the abdomen. Which would this indicate? 1. bleeding 2. infection 3. renal colic 4. normal, expected pain

1. bleeding

The nurse is monitoring an older client suspected of having a UTI for signs of infection. Which signs/symptom is likely to present first? 1. fever 2. urgency 3. confusion 4. frequency

3. confusion

A client who suffered a crush injury to the leg has a highly positive urine myoglobin level. The nurse plans to monitor this particular client carefully for signs of which complication? Respiratory failure Brain attack (stroke) Myocardial infarction Acute tubular necrosis

Acute tubular necrosis The normal urine myoglobin level is negative. After extensive muscle destruction or damage, myoglobin is released into the bloodstream, where it is cleared from the body by the kidneys. When a large amount of myoglobin is being cleared from the body, the renal tubules may become clogged with myoglobin, which causes acute tubular necrosis.

A client has just undergone renal biopsy. In planning care for this client, the nurse should avoid which intervention? Test urine for occult blood periodically. Administer opioid analgesics as needed. Ambulate in the room and hall for short distances. Encourage fluids to at least 3 L in the first 24 hours.

Ambulate in the room and hall for short distances. After renal biopsy, bed rest is maintained for at least 24 hours. The client's vital signs and puncture site are assessed frequently during this time. Urine is tested periodically for occult blood to detect bleeding as a complication.

A client is admitted to the surgical nursing unit following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. The client has a bladder irrigation infusing, and output is light cherry colored. The blood pressure is 134/82 mm Hg, the pulse is 84 beats per minute, and the client is afebrile with a respiratory rate of 18 breaths per minute. The licensed practical nurse (LPN) assisting in caring for the client collects assessment data 1 hour after admission to the nursing unit. The LPN notifies the registered nurse (RN) if which is noted on data collection? Red urine Pain-related to bladder spasms Urinary output of 200 mL greater than intake Blood pressure of 102/50 mm Hg, pulse 110 beats per minute

Blood pressure of 102/50 mm Hg, pulse 110 beats per minute A rapid pulse with a low blood pressure is a potential sign of excessive blood loss. The LPN would notify the RN, who would then contact the health care provider. Bladder spasms are expected to occur following surgery and are treated with medication. Some hematuria is usual for several days after surgery and is managed initially by increasing the flow rate of the bladder irrigation

The nurse is caring for a hospitalized client following cystoscopy and is monitoring for signs of complications associated with the procedure. Which result noted in the first few hours following the procedure indicates the need to notify the registered nurse?

Bloody urine with clots The client may have clear, yellow, or pink-tinged urine after cystoscopy. Bloody urine with clots is always an abnormal finding and should be reported immediately.

A client arrives at the ambulatory care clinic with low abdominal pain. A routine urine specimen reveals hematuria. The client does not have a fever. The nurse should next ask the client about history of which condition? Pyelonephritis Glomerulonephritis Renal cancer in the client's family Blow or trauma to the bladder or abdomen

Blow or trauma to the bladder or abdomen Bladder trauma or injury should be considered or suspected in the client with low abdominal pain and hematuria.

A client's kidneys are retaining greater amounts of sodium. The nurse anticipates that the kidneys are also retaining greater amounts of which other substances?

Chloride and bicarbonate Sodium is a cation. When sodium retention is increased, the kidney also has increased reabsorption of chloride and bicarbonate, which are anions.

A client with acute glomerulonephritis had a urinalysis sent to the laboratory. The report reveals that there is hematuria and proteinuria in the urine. The nurse interprets that these results are which?

Consistent with glomerulonephritis Gross hematuria and proteinuria are the cardinal signs of glomerulonephritis. The urine may be small in volume, dark or smoky from the hematuria, and foamy from the proteinuria.

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia (BPH), the nurse questions the client about the use of which medication? Diuretics Antibiotics Antitussives Decongestants

Decongestants In the client with BPH, episodes of urinary retention can be triggered by certain medications, such as decongestants, anticholinergics, and antidepressants. The client should be questioned about the use of these medications if presenting with urinary retention

The nurse is reviewing the client's record and notes that the health care provider has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? Select all that apply. Elevated serum creatinine level Elevated thrombocyte cell count Decreased red blood cell (RBC) count Decreased white blood cell (WBC) count Elevated blood urea nitrogen (BUN) level

Decreased red blood cell (RBC) count Elevated serum creatinine level Elevated blood urea nitrogen (BUN) level

The nurse is speaking with a client who underwent a minimally invasive procedure treatment for recurrent urolithiasis. Which instructions are appropriate to reinforce in the teaching plan? Select all that apply. Drink at least 3000 mL of fluid each day. Expect some intermittent hematuria to occur. Take acetaminophen if chills and fever occur. Complete the full course of prescribed antibiotics. Filter urine and collect any stones to take to the urological primary health care provider.

Drink at least 3000 mL of fluid each day. Complete the full course of prescribed antibiotics. Filter urine and collect any stones to take to the urological health care provider. Rationale: Kidney stones, or urolithiasis, are often treated with minimally invasive surgical procedures that may include placement of a stent. The stent allows passage of the stone without further irritation of the ureter. Clients should drink at least 3 L of fluid to promote passage of the stone and prevent future stone formation. Filtering the urine and retrieving the stone allows stone analysis. Further preventive treatment is prescribed based on the type of stone. It is important that clients complete the course of prescribed antibiotics to prevent infection after the procedure. Clients should contact the urological primary health care provider if hematuria or fever occur and not self-treat.

The nurse is collecting data from a client with epididymitis. The nurse should expect to note which signs and symptoms of this problem? Diarrhea, groin pain, and scrotal edema Fever, diarrhea, groin pain, and ecchymosis Fever, nausea and vomiting, and painful scrotal edema Nausea and vomiting, and scrotal edema with ecchymosis

Fever, nausea and vomiting, and painful scrotal edema Typical signs and symptoms of epididymitis include scrotal pain and edema, which often are accompanied by fever, nausea and vomiting, and chills. It most often is caused by infection, although sometimes it can be caused by trauma.

The nurse is reviewing the history and physical examination of a client diagnosed with polycystic kidney disease. Which data should the nurse expect to see? Select all that apply. Hematuria Flank or lumbar pain Client age 20 years old Palpable abdominal mass History of urinary tract infections

Hematuria Flank or lumbar pain History of urinary tract infections In polycystic kidney disease the client is generally asymptomatic under 30 to 40 years of age. This disorder begins with various types of pain: dull, aching abdominal, lower back, or flank pain (or it begins with colicky pain that begins abruptly). Characteristic symptoms also include hematuria, urinary tract infection, kidney stones, and obstructive uropathy with anuria.

The nurse is admitting a client with chronic kidney disease (CKD) to the nursing unit. Does the nurse monitor the client for which frequent cardiovascular sign that occurs in CKD? Hypertension Hypotension Tachycardia Bradycardia

Hypertension Hypertension is the most common cardiovascular finding in the client with CKD. It is a result of a number of mechanisms, including volume overload, renin-angiotensin system stimulation, vasoconstriction from sympathetic stimulation, and absence of prostaglandins.

A client with chlamydial infection has received instructions on self-care and prevention of further infection. The nurse determines that the client needs further teaching if the client states which? I will use latex condoms to prevent disease transmission. I will return to the clinic as requested for a follow-up culture in 1 week. I will use an antibiotic prophylactically to prevent symptoms of Chlamydia. I will reduce the chance of reinfection by limiting the number of sexual partners.

I will use an antibiotic prophylactically to prevent symptoms of Chlamydia. Antibiotics are not taken prophylactically to prevent acquisition of urethritis from Chlamydia. The risk of reinfection can be reduced by limiting the number of sexual partners and by the use of condoms.

the client has undergone transurethral resection of the prostate (TURP) a few hours ago to treat symptoms of benign prostatic hypertrophy. The nurse notes bright red blood and clots in the urinary catheter drainage bag. Which response should be the nurse's initial action? Contact the client's surgeon to report the bleeding. Remove a small amount of fluid from the retention bulb. Increase the flow rate of the continuous bladder irrigation. Remove the indwelling catheter and encourage increased oral fluids.

Increase the flow rate of the continuous bladder irrigation. Increasing the flow rate of the continuous bladder irrigation usually controls bleeding and clot formation, and this should be the nurse's first action. If this is ineffective, then notification of the surgeon is appropriate.

The nurse is caring for a hemodialysis client who has been receiving treatment for several years and is not a candidate for kidney transplant. The nurse knows that the majority of deaths of hemodialysis clients are related to which causes? Select all that apply. Stroke Trauma Malignancies Infectious complications Myocardial infarction (MI) Peptic ulcer disease (PUD)

Infectious complications. Stroke. Myocardial infarction (MI). Rationale: The majority of deaths of hemodialysis clients are related to cardiovascular events such as stroke and myocardial infarction and infectious complications.

A client with end-stage kidney disease (ESKD) undergoes a surgical procedure to create an arteriovenous fistula for hemodialysis in the upper extremity. The nurse should take which actions when the client returns from surgery? Select all that apply. Monitor pain and administer analgesics. Monitor bleeding and swelling at the site. Monitor for circulation above the fistula site. Measure the blood pressure in the arm every hour. Check for audible bruit and palpable thrill at the fistula site.

Monitor pain and administer analgesics. Monitor bleeding and swelling at the site. Check for audible bruit and palpable thrill at the fistula site.

A client hospitalized with urolithiasis has a sudden significant decrease in urine output. The nurse should perform which action? Notify the registered nurse. Obtain a urine-specific gravity. Tell the client to drink increased fluids. Replace the Foley catheter with a new one.

Notify the registered nurse. A sudden significant decrease in urine output, to either oliguria or anuria, represents obstruction of the urinary tract, usually at the bladder neck or urethra. This represents a medical emergency, requiring prompt treatment to preserve kidney function.

The nurse is urging a client to cough and deep breathe after a nephrectomy. The client tells the nurse, "That's easy for you to say! You don't have to do this." The nurse interprets that the client's statement is likely a result of which contributing factor? A stress response to the ordeal of surgery A latent fear of needing dialysis if the surgery is unsuccessful Effects of circulating metabolites that have not been excreted by the remaining kidney Pain that is intensified because the location of the incision is near the diaphragm

Pain that is intensified because the location of the incision is near the diaphragm After nephrectomy, the client may be in considerable pain. This is due to the size of the incision and its location near the diaphragm, which makes coughing and deep breathing so uncomfortable.

The nurse is admitting a client to the nursing unit who has returned from the postanesthesia care unit following a prostatectomy. The client has a three-way Foley catheter with continuous bladder irrigation. The nurse should maintain the flow rate of the continuous bladder infusion to maintain which urine output characteristic? Red Colorless Yellow with small clots Pale yellow or slightly pink

Pale yellow or slightly pink. Bladder irrigant is not infused at a preset rate, but rather it is increased or decreased to maintain urine that is clear or pale yellow or that has just a slight pink tinge. The infusion rate should be increased if the drainage is red or if clots are seen.

A hemodialysis client with a left-arm fistula is at risk for arterial steal syndrome. The nurse monitors this client for which signs/symptoms of this disorder? Edema and purpura of the left arm Warmth, redness, and pain in the left hand Aching pain, pallor, and edema of the left arm Pallor, diminished pulse, and pain in the left hand

Pallor, diminished pulse, and pain in the left hand. Arterial steal syndrome results from vascular insufficiency after creation of a fistula. The client exhibits pallor and diminished pulse distal to the fistula and complains of pain distal to the fistula, which is caused by tissue ischemia.

A client who had a prostatectomy has learned perineal exercises to gain control of the urinary sphincter. The nurse determines that the client needs further teaching if the client states that he will perform which action as part of these exercises? Perform the Valsalva maneuver. Tighten the muscles as if trying to prevent urination. Contract the abdominal, gluteal, and perineal muscles. Tighten the rectal sphincter while relaxing abdominal muscles.

Perform the Valsalva maneuver. The Valsalva maneuver is avoided following prostatectomy because it increases the risk of bleeding in the postoperative period. An acceptable exercise is tightening the abdominal, gluteal, and perineal muscles, as if trying to prevent urination.

The nurse is assisting in planning a diet for a client with acute kidney injury (AKI). The nurse plans to restrict which dietary component from this client's diet? Fats Vitamins Potassium Carbohydrates

Potassium In the client with renal failure, potassium intake must be restricted as much as possible (30 to 50 mEq/day). The primary mechanism of potassium removal during acute kidney injury is dialysis.

The nurse is reinforcing instructions to a client about the types of fluids that assist in the prevention and treatment of urinary tract infections (UTIs). The nurse instructs the client to consume which fluids? Select all that apply. Milk Soda Prune juice Apple juice Cranberry juice

Prune juice Apple juice Cranberry juice he client at risk for UTIs should be instructed to consume adequate amounts (2000 to 2500 mL/day) of fluids. Certain fluids can be used to minimize the risk for the development of UTI, such as prune juice, apple juice, cranberry juice, and water.

Bethanechol is prescribed for the client with urinary retention, and an injectable form of bethanechol is available for use as prescribed. The nurse informs the client of the primary health care provider's prescription, knowing that the medication will be administered by which injectable route? Intravenously Intradermally Intramuscularly Subcutaneously

Subcutaneously Rationale: The injectable form of bethanechol is intended for subcutaneous administration only. Bethanechol must never be injected intramuscularly or by the intravenous route because the resulting high drug levels can cause severe toxicity resulting in bloody diarrhea, bradycardia, profound hypotension, and cardiovascular collapse.

A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. Which information about this procedure should the nurse give to the client?

The client must void while the micturition process is filmed. Having to void in the presence of others can be very embarrassing for clients and actually may interfere with the client's ability to void. The nurse teaches the client about the procedure to try to minimize stress from lack of preparation and gives the client encouragement and emotional support.

The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which clients? The client with cataracts The client with varicose veins The client with type 2 diabetes mellitus The client with chronic obstructive pulmonary disease (COPD)

The client with chronic obstructive pulmonary disease (COPD) Peritoneal dialysis requires instillation of approximately 2 L of a dialysate solution into the peritoneal space. A client with COPD would be at high risk for developing respiratory distress if the respiratory system were to be further compromised by the instillation of the dialysate solution and the resulting upward displacement of the diaphragm.

The spouse of a client with acute kidney injury secondary to heart failure asks the nurse how this could happen. The nurse plans to base a response in part on the fact that which statement is true?

The kidneys generally require and receive about 20% to 25% of the resting cardiac output. The kidneys normally receive about 20% to 25% of the cardiac output and require adequate perfusion to function properly. With a significant or prolonged decrease in blood supply, the kidneys can fail.

The nurse is assisting in planning a teaching session with a client diagnosed with urethritis caused by infection with Chlamydia. The nurse should plan to include which point in the teaching session? The most serious complication of this infection is sterility. Sexual partners during the last 12 months should be notified and treated. Medication therapy should be continued for 2 months without interruption. The infection can be prevented by using spermicide to alter the pH in the perineal area.

The most serious complication of this infection is sterility. The most serious complication of chlamydial infection is sterility. The infection can be prevented by the use of latex condoms.. All sexual partners during the 30 days before diagnosis should be notified, examined, and treated as necessary.

Bethanechol chloride is prescribed for a client. When should the nurse tell the client to take the medication? With meals Two hours after meals With a snack in the afternoon At bedtime with crackers and cheese

Two hours after meals Rationale: Administration of bethanechol with meals can cause nausea and vomiting in the client. To avoid this problem, oral doses should be administered 1 hour before meals or 2 hours after meals.

A long-term care nurse notes that an older client who is normally alert has become progressively confused and irritable. What diagnostic tests should the nurse anticipate the health care provider to prescribe? Select all that apply. Urinalysis Lipid profile Chemistry profile Coagulation studies Stool for occult blood Complete blood count

Urinalysis Complete blood count Confusion may be one of the first signs of cystitis or UTI in older adults. If a patient who is normally alert becomes confused, assess the urine for cloudiness, foul odor, or hematuria (blood in the urine), and check for signs of infection (fever, increased white blood cell [WBC] count).

Oxybutynin chloride is prescribed for a client with a neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? 1. pallor 2. drowsiness 3. bradycardia 4. restlessness

4. restlessness Rationale: Toxicity (overdose) of this medication produces central nervous system excitation, such as nervousness, restlessness, hallucinations, and irritability. Other signs of toxicity include hypotension or hypertension, confusion, tachycardia, flushed or red face, and signs of respiratory depression. Drowsiness is a frequent side effect of the medication but does not indicate overdose.

Trimethoprim/Sulfamethoxazole is prescribed for a client. The nurse should instruct the client to report which symptom if it developed during the course of this medication therapy? 1. nausea 2. diarrhea 3. headache 4. sore throat

4. sore throat Rationale: Clients taking trimethoprim-sulfamethoxazole should be informed about early signs of blood disorders that can occur from this medication. These include sore throat, fever, and pallor, and the client should be instructed to notify the PHCP if these symptoms occur. The other options do not require PHCP notification.

The nurse is monitoring an older client suspected of having a urinary tract infection (UTI) for signs of the infection. Which sign/symptom should occur first? Fever Urgency Confusion Frequency

Confusion. In an older client, the only symptom of a UTI may be something as vague as increasing mental confusion or frequent unexplained falls. Frequency and urgency may commonly occur in an older client, and fever can be associated with a variety of conditions.

A client complains of leaking urine whenever she sneezes, coughs, or laughs. The nurse recognizes that this report is consistent with which type of incontinence?

Stress Stress incontinence is caused by coughing, laughing, and other activities that increase intra-abdominal pressure. Reflex incontinence, sometimes called "overflow incontinence," is a loss of urine that is uncontrollable and occurs at predictable intervals.

The use of peritoneal dialysis for the treatment of chronic kidney disease would be contraindicated for which client? The client with hypothyroidism The client with severe emphysema The client with type 2 diabetes mellitus The client with severe peripheral vascular disease

The client with severe emphysema. Peritoneal dialysis requires the instillation of approximately 2 L of a dialysate solution into the peritoneal space. This is known as the "dwell time." While this fluid remains in the peritoneal space, it causes upward displacement of the diaphragm, resulting in decreased lung expansion.

A client is scheduled for intravenous pyelography. Which PRIORITY nursing action should the nurse take? 1. restrict fluids 2. administer a sedative 3. determine if there is a history of allergies 4. administer an oral preparation of radiopaque dye

3. determine if there is a history of allergies

The nurse has reinforced instructions to the client with a cystocele about Kegel exercises. The nurse determines that the client has not fully understood the directions if the client makes which statement? "Stop and start the stream of urine several times during avoiding." "Tighten perineal muscles for up to 10 seconds several times a day." "Tighten perineal muscles for up to 5 minutes three or four times a day." "Begin voiding and then stop the stream, holding residual urine for an hour."

"Begin voiding and then stop the stream, holding residual urine for an hour." Kegel exercises strengthen the perineal floor and are useful to prevent and manage cystocele, rectocele, and enterocele. There are several acceptable ways to perform Kegel exercises. These involve starting and stopping the flow of urine either once for up to 5 minutes, or several times during a single voiding for about 5 seconds.

A client has received instructions on self-management of peritoneal dialysis. The nurse determines that the client needs further teaching if the client makes which statement? "I will monitor my weight daily." "I will take my vital signs daily." "I will use a meticulous aseptic technique for dialysate bag changes." "I will use a strong adhesive tape to anchor the catheter dressing."

"I will use a strong adhesive tape to anchor the catheter dressing." The client is at risk for impairment of skin integrity resulting from the presence of the catheter, exposure to moisture, and irritation from tape and cleansing solutions

Phenazopyridine hydrochloride is prescribed for a client for symptomatic relief of pain resulting from a lower UTI. Which should the nurse reinforce to the client? 1. take the medication at bedtime 2. take the medication before meals 3. discontinue the medication if a headache occurs 4. a reddish-orange discoloration of the urine may occur

4. a reddish-orange discoloration of the urine may occur Rationale: The nurse should instruct the client that a reddish-orange discoloration of urine may occur. The nurse also should instruct the client that this discoloration can stain fabric. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant discontinuation of the medication.

A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate? 1. advancing uremia 2. phosphate overdose 3. folic acid deficiency 4. aluminum intoxication

4. aluminum intoxication

The client who has a cold is seen in the ER with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which class of medication? 1. diuretics 2. antibiotics 3. antitussives 4. decongestants

4. decongestants

The nurse is collecting data from a client who has had benign prostatic hyperplasia (BPH) in the past. To determine whether the client is currently experiencing an exacerbation of BP, the nurse should ask the client about the presence of which early symptom? 1. nocturia 2. urinary retention 3. urge incontinence 4. decreased force in the stream of urine

4. decreased force in the stream of urine

A client with end-stage kidney disease (ESKD) begins peritoneal dialysis. Does the nurse observe for which signs/symptoms indicating peritonitis? Select all that apply. Nausea and vomiting Poor dialysate outflow Abdominal tenderness Cloudy peritoneal effluent Oral temperature of 38° C Clear fluid leakage at the catheter exit site

Abdominal tenderness Cloudy peritoneal effluent Oral temperature of 38° C Nausea and vomiting Peritoneal dialysis is a treatment used in clients with ESKD as an alternative to hemodialysis. The procedure involves the instillation of dialysate fluid into the peritoneal cavity where excess body wastes, fluid, and electrolytes are removed through diffusion and osmosis across the semipermeable peritoneal membrane and peritoneal capillaries. A peritoneal catheter is surgically placed into the abdominal cavity and is used to instill and drain the dialysate fluid, known as effluent. Peritonitis, or infection of the peritoneal cavity, is a possible complication of peritoneal dialysis. The effluent becomes cloudy instead of the normal clear straw color, and the client has symptoms of abdominal tenderness and pain, nausea, vomiting, and fever. Thirty-eight degrees Celsius is an elevated temperature indicating fever, a sign of infection. Poor dialysate outflow is usually caused by constipation. Leakage of clear fluid at the exit site of the peritoneal catheter is more likely to occur in obese or diabetic clients. It occurs as the client physiologically adjusts to the instillation of 2 L of dialysate fluid into the abdominal cavity.

The nurse is preparing a client scheduled for an intravenous pyelogram (IVP). The nurse should take important action before the test? Administer a sedative. Encourage fluid intake. Ask about allergies to iodine or shellfish. Administer an oral preparation of radiopaque dye.

Ask about allergies to iodine or shellfish. Some IVP dye is iodine based. It can cause allergic reactions manifested by itching, hives, rash, a tight feeling in the throat, shortness of breath, and bronchospasm.

After a renal biopsy, the client complains of pain at the biopsy site, which radiates to the front of the abdomen. Which would this indicate? Bleeding Infection Renal colic Normal, expected pain

Bleeding If pain originates at the biopsy site and begins to radiate to the flank area and around the front of the abdomen, bleeding should be suspected. Hypotension, a decreasing hematocrit, and gross or microscopic hematuria should also indicate bleeding.

A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigations postoperatively. Which are the signs/symptoms of transurethral resection (TUR) syndrome? Tachycardia and diarrhea Bradycardia and confusion Increased urinary output and anemia Decreased urinary output and bladder spasms

Bradycardia and confusion TURP syndrome is caused by increased absorption of nonelectrolyte irrigating fluid used during surgery. The client may show signs of cerebral edema and increased intracranial pressure, such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual disturbances, and nausea and vomiting.

The nurse is caring for a client who received a recent kidney transplant. Besides actual rejection of the transplant, which are some of the most important complications this client is at risk for? Select all that apply. Colitis Malignancies Respiratory disease Cardiovascular disease Susceptibility to infection Corticosteroid-related complications

Cardiovascular disease Susceptibility to infection Corticosteroid-related complications Malignancies Rationale: Rejection is one of the major problems of kidney transplant recipients. Besides recurrence of renal disease, kidney transplant clients are also at risk for malignancies, a cardiovascular disease caused by atherosclerotic vascular disease, infection, and corticosteroid-related complications. Incidences of infection usually occur within the first month of transplant.

A client's kidneys are retaining larger than normal amounts of sodium. The nurse is reviewing the most recent laboratory data. The nurse should expect which laboratory value to be abnormal since the client is retaining sodium? Calcium 8.8 mg/dL Chloride 112 mEq/L Potassium 4.1 mEq/L Bicarbonate 23 mEq/L

Chloride 112 mEq/L Sodium is a cation. When sodium retention is increased, the kidney also has increased reabsorption of chloride and bicarbonate, which are anions. The chloride level is elevated whereas the bicarbonate level is normal. Options 1 and 3 are incorrect because calcium and potassium are cations.

A client is scheduled for intravenous pyelography (IVP). Which priority nursing action should the nurse take? Restrict fluids. Administer a sedative. Determine if there is a history of allergies. Administer an oral preparation of radiopaque dye.

Determine a history of allergies. An iodine-based dye may be used during the IVP and can cause allergic reactions such as itching, hives, rash, tight feeling in the throat, shortness of breath, and bronchospasm. Checking for allergies is the priority.

The nurse notes that a client's urinalysis report contains a notation of positive red blood cells (RBCs). The nurse interprets that this finding is unrelated to which is an item is part of the client's medical record? Diabetes mellitus History of kidney stones Concurrent anticoagulant therapy History of recent blow to the right flank

Diabetes mellitus Hematuria can be caused by trauma to the kidney, such as with blunt trauma to the lower posterior trunk or flank. Kidney stones can cause hematuria as they scrape the endothelial lining of the urinary system.

A client has been diagnosed with pyelonephritis. The nurse interprets that which health problem has placed the client at risk for this disorder? Hypoglycemia Diabetes mellitus Coronary artery disease Orthostatic hypotension

Diabetes mellitus Risk factors associated with pyelonephritis include diabetes mellitus, hypertension, chronic renal calculi, chronic cystitis, structural abnormalities of the urinary tract, presence of urinary stones, and indwelling or frequent urinary catheterization.

A client has an arteriovenous (AV) shunt in place for hemodialysis. The nurse should take which priority precaution, knowing that bleeding is a potential complication? Observe the site once per shift. Check the shunt for the presence of a bruit and thrill. Check the results of blood tests as they are prescribed. Ensure that small clamps are attached to the AV shunt dressing.

Ensure that small clamps are attached to the AV shunt dressing. An AV shunt is a cannula with two ends that are tunneled subcutaneously into an artery and a vein.

A client with a urinary tract infection with dysuria is given a prescription for phenazopyridine hydrochloride for symptom relief. Which should the nurse reinforce instructing the client about this medication? Take the medication at bedtime. Take the medication 1 hour before meals. Expect the urine to become reddish-orange. Notify the primary health care provider if a headache occurs.

Expect the urine to become reddish orange. Rationale: Phenazopyridine hydrochloride is a urinary tract analgesic with no antimicrobial properties. It can cause a reddish orange discoloration of urine and tears and can stain undergarments and soft contact lenses. The medication should be taken after meals to reduce the possibility of gastrointestinal upset. A headache is an occasional side effect of the medication and does not warrant notifying the primary health care provider.

A client newly diagnosed with renal failure will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate? Stop the dialysis. Slow the infusion. Decrease the amount to be infused. Explain that the pain will subside after the first few exchanges.

Explain that the pain will subside after the first few exchanges. Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, it disappears after a week or two.

The nurse is caring for a client with epididymitis. The nurse anticipates noting which group of findings on data collection? Diarrhea, groin pain, and scrotal edema Fever, diarrhea, groin pain, and ecchymosis Fever, nausea and vomiting, and painful scrotal edema Nausea, vomiting, and scrotal edema with widespread ecchymosis

Fever, nausea and vomiting, and painful scrotal edema. Typical signs and symptoms of epididymitis include scrotal pain and edema, which are often accompanied by fever, nausea and vomiting, and chills.

The nurse is providing instructions to the client regarding the complications of peritoneal dialysis. The nurse instructs the client that which symptom is likely associated with the onset of peritonitis?

Fever. The signs of peritonitis include fever, nausea, malaise, rebound abdominal tenderness, and cloudy dialysate output

Propantheline bromide is prescribed for a client with bladder spasms. Which disorder, noted in the client's record, alerts the nurse to question the prescription for this medication? Glaucoma Myxedema Hypothyroidism Coronary artery disease

Glaucoma

The nurse is assigned to care for a client who has returned to the nursing unit following left nephrectomy. The nurse places the highest priority on monitoring which data? Hourly urine output Oxygen saturation levels Ability to turn side to side Tolerance for sips of clear liquids

Hourly urine output Following a nephrectomy, it is imperative to measure the urine output hourly. This is done to monitor the function of the remaining kidney and to detect renal failure early if it occurs.

Which conditions place the client at risk for developing acute postrenal failure? Dehydration Hydronephrosis Rhabdomyolysis Glomerulonephritis

Hydronephrosis Postrenal failure is caused by an obstruction in the urinary tract, anywhere from the tubules to the urethral meatus. Some causes of obstruction include calculi, tumors, prostatic hypertrophy, or strictures, which impede the normal flow of urine.

The client with diabetes mellitus receiving peritoneal dialysis asks the nurse why it is important to leave the dialysate infused only for a specific amount of time. The nurse responds that not adhering to the dwell time can increase the risk of the client experiencing which complication? Infection Fluid overload Hyperglycemia Disequilibrium syndrome

Hyperglycemia Dialysate contains glucose, which helps remove fluids through an osmotic gradient. An extended dwell time increases the risk of hyperglycemia in diabetic clients as a result of the absorption of glucose from the dialysate and electrolyte changes.

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the dwell time for the dialysis at the prescribed time because of the risk for which complication? Peritonitis Hyperglycemia Hyperphosphatemia Disequilibrium syndrome

Hyperglycemia. An extended dwell time increases the risk of hyperglycemia in the client with diabetes mellitus as a result of absorption of glucose from the dialysate and electrolyte changes. Diabetic clients may require extra insulin when receiving peritoneal dialysis.

Which actions are included in the nursing care of the client undergoing peritoneal dialysis? Select all that apply Monitor vital signs including temperature. Weigh the client before and after dialysis. Check color and volume of dialysate solution. Instruct the client to remain supine until the dialysate is drained. Maintain aseptic technique when accessing the peritoneal catheter.

Monitor vital signs including temperature. Weigh the client before and after dialysis. Check color and volume of dialysate solution. Maintain aseptic technique when accessing the peritoneal catheter.

Which observations by the nurse caring for clients on a hospital medical-surgical unit should be immediately reported to the health care provider? Select all that apply. Pink-colored urine voided by a client admitted for urolithiasis Mucous shreds noted in the urine of a client who has an ileal conduit New confused mental state and pulse rate of 106 beats per minute in a 72-year-old client No urinary output for 24 hours in a client who has hemodialysis 3 times weekly A volume of 105 mL of urine over 4 hours in the collection bag of a 1-day postoperative client

New confused mental state and pulse rate of 106 beats per minute in a 72-year-old client. A volume of 105 mL of urine over 4 hours in the collection bag of a 1-day postoperative client Rationale: The nurse should report the new confusion and slightly tachycardic condition of the older client because these data suggest symptoms of a urinary tract infection requiring antibiotic therapy. The nurse should report the low urinary output in the postoperative client so interventions can be prescribed to diagnose and/or avoid acute kidney injury (AKI). Slight hematuria is an expected finding in a client with urolithiasis (renal stones). Urine with mucous shreds is an expected finding in a client with an ileal conduit because the portion of ileum that functions as the "bladder" is bowel mucosa. Some clients who receive routine hemodialysis produce small amounts of urine but others do not urinate because the kidney function is now done through hemodialysis.

The nurse is evaluating the assessment of a client's arteriovenous fistula being used for hemodialysis. Which findings would prompt the nurse to notify the health care provider immediately? Select all that apply. No thrill palpated at the fistula site No bruit auscultated at the fistula site Dialysis treatment lasting longer than 3 hours Absent pulse distal to the arteriovenous fistula Fistula site transparent dressing last changed 8 days ago

No thrill palpated at fistula site Absent pulse distal to the arteriovenous fistula No bruit auscultated at the fistula site Rationale: The primary health care provider must be notified immediately when there is no thrill or bruit assessed at the fistula site or if there is no pulse noted distal to the site. This indicates a clot. Hemodialysis treatments usually last about 3 to 4 hours. Dressings to the site are changed every 7 days, but it is not necessary to immediately notify the primary health care provider if it has not been changed in 8 days.

A client is admitted to the emergency department following a fall from a horse. The health care provider (HCP) prescribes the insertion of an indwelling urinary catheter. The nurse notes blood at the urinary meatus while preparing for the procedure. Which action should the nurse take? Use a smaller catheter. Notify the primary health care provider. Administer pain medication before inserting the catheter. Use extra povidone-iodine solution in cleansing the meatus.

Notify the health care provider. The presence of blood at the urinary meatus may indicate urethral trauma or disruption. The nurse notifies the HCP, knowing that the client should not be catheterized until the cause of the bleeding is determined by diagnostic testing.

The nurse is reinforcing instructions to a client with renal calculi about how to change the urine pH to be more acidic. The nurse determines that the client needs further teaching if the client states which type of drink is acceptable? Prune juice Lemon juice Orange juice Cranberry juice

Orange juice Orange juice should be avoided because it will make the urine more alkaline. Changing the urine pH can prevent or reduce the incidence of renal calculi. Ascorbic acid or dietary modifications (e.g., cranberry juice, prunes, or lemon juice) can be used to acidify urine.

The nurse is assessing the patency of an arteriovenous fistula in the left arm of a client who is receiving hemodialysis for the treatment of chronic kidney disease. Which finding indicates that the fistula is patent? Palpation of a thrill over the fistula Presence of a radial pulse in the left wrist Absence of a bruit on auscultation of the fistula Capillary refill less than 3 seconds in the nail beds of the left hand

Palpation of a thrill over the fistula The nurse assesses the patency of the fistula by palpating for the presence of a thrill or auscultating for a bruit. The presence of a thrill and bruit indicates patency of the fistula.

The nurse prepares to administer sodium polystyrene sulfonate to a client with chronic kidney disease for which laboratory abnormality? Sodium level of 152 mEq/L Creatinine level of 1.0 mg/dL Ammonia level of 30 mcg/dL Potassium level of 7.2 mEq/L

Potassium level of 7.2 mEq/L Rationale: Sodium polystyrene sulfonate is a cation exchange resin used in the treatment of hyperkalemia. The resin either passes through the intestine or is retained in the colon. It releases sodium ions in exchange for primarily potassium ions. The therapeutic effect occurs 2 to 12 hours after oral administration and longer after rectal administration.

A client with acute kidney injury (AKI) has been treated with sodium polystyrene sulfonate (Kayexalate) by mouth. The nurse evaluates this therapy as effective if which value is noted on follow-up laboratory testing? Calcium, 9.8 mg/dL Sodium, 142 mEq/L Potassium, 4.9 mEq/L Phosphorus, 3.9 mg/dL

Potassium, 4.9 mEq/L Of all the electrolyte imbalances that accompany renal failure, hyperkalemia is the most dangerous because it can lead to cardiac dysrhythmias and death. If the potassium level rises too high, sodium polystyrene sulfonate may be given to cause excretion of potassium through the gastrointestinal tract.

The nurse caring for a client taking tamsulosin determines that which finding indicates the need for follow-up? Vertigo Nasal congestion Blood pressure of 125/80 mm Hg Pulse rate of 120 beats per minute

Pulse rate of 120 beats per minute Rationale: Tamsulosin is classified as benign prostatic hyperplasia agent and acts by relaxing smooth muscle and increasing urinary flow. An adverse effect of this medication is first-dose syncope, which usually occurs within the first 30 to 90 minutes of the initial dose. This is commonly preceded by tachycardia (pulse of 120 to 160 beats per minute). Side effects of this medication include dizziness, drowsiness, nasal congestion, and vertigo.

A client with acute glomerulonephritis is admitted to the nursing unit. The nurse should plan to do which action immediately on admission? Ambulate the client frequently. Encourage a diet that is high in protein. Monitor the temperature every 2 hours. Remove the water pitcher from the bedside.

Remove the water pitcher from the bedside. The client with acute glomerulonephritis commonly experiences fluid volume excess and fatigue. Interventions include fluid restriction and ongoing monitoring of weight, intake, and output.

Chlamydia is a sexually transmitted infection and is frequently called "non-gonococcal urethritis" in the male client. It requires no special precautions

Standard precautions are sufficient because the infection is transmitted sexually. Chlamydia is a sexually transmitted infection and is frequently called "non-gonococcal urethritis" in the male client.

A client with a history of prostatic hypertrophy has purchased the over-the-counter medication, diphenhydramine (Benadryl), to treat symptoms of a runny nose. The nurse explains to the client that this medication combined with prostatic hypertrophy could cause exacerbation of which symptom? Urinary retention Lowered heart rate Excessive drooling Excessive sweating

Urinary retention Diphenhydramine (Benadryl) is used to treat allergy symptoms. It should be used cautiously with prostatic hypertrophy because the anticholinergic effects of the medication could cause exacerbation of symptoms, including urinary retention or hesitancy.

The nurse is assessing a client with suspected acute kidney injury. Which finding would support a diagnosis of acute intrarenal failure? Urine output of 30 mL/hr for the past 24 hours Urine analysis positive for casts and cellular debris Renal ultrasound indicating the presence of ureteral calculi Blood urea nitrogen (BUN) level of 48 mg/dL and creatinine level of 1.2 mg/dL

Urine analysis positive for casts and cellular debris Acute tubular necrosis is responsible for 90% of acute intrarenal failure cases, and in these cases, the tubular epithelium is destroyed. The debris from the destruction of the epithelial cells can be detected in the urinalysis of a client with acute intrarenal failure.

The nurse is caring for a hospitalized client following cystoscopy. Which discharge instructions are given to the client? Select all that apply. Use antispasmodics for pain. Restrict oral fluids for 1 to 2 days. Expect pink-tinged urine for 1 week. Take sitz baths for voiding discomfort. Report severe pain to the health care provider.

Use antispasmodics for pain. Take sitz baths for voiding discomfort. Report severe pain to the health care provider.

A client with prostatitis resulting from kidney infection has received instructions on the management of the condition at home and prevention of recurrence. Which statement indicates that the client understood the instructions? Stop antibiotic therapy when the pain subsides. Exercise as much as possible to stimulate circulation. Use warm sitz baths and analgesics to increase comfort. Keep fluid intake to a minimum to decrease the need to void.

Use warm sitz baths and analgesics to increase comfort. Treatment of prostatitis includes medication with antibiotics, analgesics, and stool softeners. The client is also taught to rest, increase fluid intake, and use sitz baths for comfort. Antimicrobial therapy is always continued until the prescription is completely finished.

The nurse is assigned to care for a client who has just returned to the nursing unit after having hemodialysis for the first time. The nurse monitors the client carefully for which signs and symptoms of disequilibrium syndrome? Vomiting and headaches Lethargy and hypertension Hypertension and sleepiness Abdominal pain and hypotension

Vomiting and headaches A complication that can occur during early dialysis is disequilibrium syndrome. This syndrome results from a high osmotic gradient in the brain following the rapid removal of fluid that can occur during hemodialysis.

A client contacts the health care provider's office to report she is not feeling well, has burned with urination, and suspects she may have a urinary tract infection. The nurse instructs the client to collect a urine specimen for testing. Which urinalysis findings indicate the presence of a urinary tract infection? Select all that apply. Nitrites, present Turbidity, clear Ketones, moderate White blood cells, 10 Specific gravity, 1.025 Leukocyte esterase, present

White blood cells, 10 Leukoesterase, present Nitrites, present

A urinary analgesic is prescribed for a client with a urinary tract infection. When should the nurse tell the client that it is best to take the medication? With meals At bedtime One hour before meals In the morning before breakfast

With meals Rationale: A urinary antiseptic is administered with meals to decrease gastrointestinal side effects. Options 2, 3, and 4 are incorrect.

A client with chronic kidney disease is receiving epoetin alfa. Which laboratory result would indicate a therapeutic effect of the medication? 1. hematocrit of 33% 2. platelet count of 400,000 3. WBC count of 6000 4. BUN level 15

1. hematocrit of 33% Rationale: Epoetin alfa is synthetic erythropoietin, which the kidneys produce to stimulate red blood cell production in the bone marrow. It is used to treat anemia associated with chronic kidney disease. The normal hematocrit level is Male: 42% to 52% (0.42 to 0.52); Female: 37% to 47% (0.37 to 0.47). Therapeutic effect is seen when the hematocrit reaches between 30% and 33% (0.30 and 0.33). The normal platelet count is 150,000 to 400,000 mm3 (150 to 400 × 109/L). The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal white blood cell count is 5000 to 10,000 mm3 (5 to 10 × 109/L). Platelet production, white blood cell production, and blood urea nitrogen do not respond to erythropoietin.

The nurse is reviewing the clients record and notes that the PHCP has documented that the client has a renal disorder. Which laboratory results would indicate a decrease in renal function? SELECT ALL THAT APPLY 1.elevated serum creatinine level 2. elevated thrombocyte cell count 3. decreased RBC count 4. decreased WBC count 5. elevated BUN level

1.elevated serum creatinine level 3. decreased RBC count 5. elevated BUN level

A client with benign prostatic hypertrophy (BPH) undergoes a transurethral resection of the prostate (TURP) and is receiving continuous bladder irrigation's postoperatiely. Which are the sign/symptoms of TURP syndrome? 1. tachycardia and diarrhea 2. bradycardia and confusion 3. increased urinary output and anemia 4. decreased urinary output and bladder spasms

2. bradycardia and confusion

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions? Select all that apply. 1. contact the nephrologist 2. check the level of the drainage bag 3. reposition the client to his or her side 4. place the client in a good body alignment 5. check the peritoneal dialysis system for kinks 6.. increase the flow rate of the peritoneal dialysis solution

2. check the level of the drainage bag 3. reposition the client to his or her side 4. place the client in a good body alignment 5. check the peritoneal dialysis system for kinks

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication? 1. peritonitis 2. hyperglycemia 3. hyperphosphatemia 4. disequilibrium syndrome

2. hyperglycemia

The nurse is reinforcing discharge instructions to a client receiving sulfadiazine. Which should be included in the list of instructions? 1. restrict fluid intake 2. maintain a high fluid intake 3. decrease the dosage when symptoms are improving to prevent an allergic response 4. if the urine is dark brown, call the PHCP immediately

2. maintain a high fluid intake Rationale: Each dose of sulfadiazine should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfadiazine cause urine to turn dark brown or red. This does not indicate the need to notify the PHCP.

Bethanechol chloride is prescribed for a client with urinary retention. Which disorder should be a contraindication to the administration of this medication? 1. gastric atony 2. urinary strictures 3. neurogenic atony

2. urinary strictures Rationale: Bethanechol chloride can be harmful to clients with urinary tract obstruction or weakness of the bladder wall. The medication has the ability to contract the bladder and thereby increase pressure within the urinary tract. Elevation of pressure within the urinary tract could rupture the bladder in clients with these conditions

Following kidney transplantation, cyclosporine (Sandimmune) is prescribed for a client. Which laboratory result would indicate an adverse effect from the use of this medication? 1. hemoglobin level 14.0 2. creatinine level 0.6 3. BUN 25 4. fasting blood glucose level of 99

3. BUN 25 Cyclosporine is an immunosuppressant. Nephrotoxicity can occur from the use of cyclosporine. Nephrotoxicity is evaluated by monitoring for elevated blood urea nitrogen and serum creatinine levels. The normal blood urea nitrogen level is 10 to 20 mg/dL (3.6 to 7.1 mmol/L). The normal creatinine level for a male is 0.6 to 1.2 mg/dL (53 to 106 mcmol/L) and for a female 0.5 to 1.1 mg/dL (44 to 97 mcmol/L). Cyclosporine can lower complete blood cell count levels. A normal hemoglobin is Male: 14 to 18 g/dL (140 to 180 mmol/L); Female: 12 to 16 g/dL (120 to 160 mmol/L). Anormal hemoglobin is not an adverse effect. Cyclosporine does affect the glucose level. The normal fasting glucose is 70 to 110 mg/dL (4 to 6 mmol/L).

The nurse who is administering bethanechol chloride is monitoring for acute toxicity associated with medication. The nurse should check for which sign of toxicity? 1. dry skin 2. dry mouth 3. bradycardia 4. signs of dehydration

3. bradycardia Rationale: Toxicity (overdose) produces manifestations of excessive muscarinic stimulation such as salivation, sweating, involuntary urination and defecation, bradycardia, and severe hypotension. Treatment includes supportive measures and the administration of atropine sulfate subcutaneously or intravenously.

A client has epididymitis as a complication of a UTI . The nurse is giving the client instructions to prevent a recurrence. The nurse determines that the client needs FURTHER teaching if the client states the intention to do which action? 1. drink an increased amount of fluids 2. limit the force of the stream during voiding 3. continue to take antibiotics until all symptoms are gone

3. continue to take antibiotics until all symptoms are gone

A client with prostatitis resulting from kidney infection has received instructions on the management of the condition at home and prevention on recurrence. Which statement indicates that the client understood the instructions? 1. stop antibiotic therapy when pain subsides 2. exercise as much as possible to stimulate circulation 3. use warm sitz baths and analgesics to increase comfort 4. keep fluid intake to a minimum ti decrease the need to void

3. use warm sitz baths and analegesics to increase comfort

In reviewing the admission assessment data and primary health care provider's prescriptions for a client with peptic ulcer disease, the nurse notes that the client has a history of renal disease. Based on this data, the nurse determines which antacid should be prescribed for this client? Magnesium oxide Aluminum hydroxide Magnesium and calcium Aluminum and magnesium combination

Aluminum hydroxide Rationale: Aluminum hydroxide lowers serum phosphate by binding with dietary phosphorus to form insoluble aluminum phosphate. The phosphate is then excreted in the feces. Aluminum hydroxide will not affect the renal system as much as other antacids. The medications identified in options 1, 3, and 4 are partially excreted by the kidneys; therefore, they may cause a problem in clients with renal disease.

The nurse is caring for a client with kidney failure. The serum phosphate level is reported as 7 mg/dL. Which medication should the nurse plan to administer as prescribed to the client? Calcitonin Calcium chloride Calcium gluconate Aluminum hydroxide gel

Aluminum hydroxide gel Rationale: The normal serum phosphate level is 3 to 4.5 mg/dL. The client in this question is experiencing hyperphosphatemia. Certain medications can be given to increase fecal excretion of phosphorus by binding phosphorus from the food in the gastrointestinal tract. Aluminum hydroxide gel is one such medication. Calcium gluconate and calcium chloride are medications used in the treatment of tetany that occurs from acute hypocalcemia. Calcitonin, a thyroid hormone, decreases the plasma calcium level by increasing the incorporation of calcium into the bones thus keeping it out of the serum.

The nurse has a prescription to collect a 24-hour urine specimen from a client. The unlicensed assistive personnel (UAP) has been instructed on the collection technique. Which action by the UAP demonstrates the UAP needs further teaching? Places the specimen on ice Discards a urine specimen collected at the start time Asks the client to void, save the specimen, and note the start time Asks the client to save a sample voided at the end of the collection time

Asks the client to void, save the specimen, and note the start time. Because the 24-hour urine test is a timed quantitative determination, the test must be started with an empty bladder.

The nurse is preparing a subcutaneous dose of bethanechol chloride prescribed for a client with urinary retention. Before giving the dose, the nurse checks to see that which medication is available on the emergency cart? Vitamin K Acetylcysteine Atropine sulfate Protamine sulfate

Atropine sulfate Rationale: Administration of bethanechol chloride could result in cholinergic overdose. The antidote is atropine sulfate (an anticholinergic), which should be readily available for use if overdose occurs. Acetylcysteine is the antidote for acetaminophen overdose. Protamine sulfate is the antidote for heparin. Vitamin K is the antidote for warfarin.

The nurse must ambulate a client who has a nephrostomy tube attached to a drainage bag. The nurse plans to do this most safely and effectively by performing which action? Changing the drainage bag to a leg collection bag Hanging the drainage bag from a walker while ambulating Tying the drainage bag to the client's waist while ambulating Asking the client to hold the drainage bag lower than the level of the bladder

Changing the drainage bag to a leg collection bag The safest approach to protect the integrity and safety of the nephrostomy tube with a mobile client is to attach the tube to a leg collection bag. This allows for greater freedom of movement while alleviating worry over accidental disconnection or dislodgement.

A client receiving nitrofurantoin calls the primary health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication? Nausea Diarrhea Anorexia Chest pain

Chest pain Rationale: Gastrointestinal (GI) effects are the most frequent adverse reactions to this medication and can be minimized by administering the medication with milk or meals. Pulmonary reactions manifested as dyspnea, chest pain, chills, fever, cough, and the presence of alveolar infiltrates on the x-ray should indicate the need to stop the treatment. These symptoms resolve in 2 to 4 days following discontinuation of this medication.

A client is seen in the health care clinic and acute pyelonephritis is suspected. The nurse reviews the client's record and should expect to note which associated signs and symptoms are documented? Select all that apply. Chills Low-grade fever Pale, dilute urine General weakness Nausea and vomiting Flank pain on the unaffected side

Chills General weakness Nausea and vomiting Typical signs and symptoms of acute pyelonephritis include high fever, chills, nausea, vomiting, flank pain on the affected side with costovertebral angle tenderness, general weakness, and headache.

A female client has a prescription for a clean-catch urine culture. After providing a sterile specimen cup to the client, the nurse should give which instruction so that the specimen is collected properly? Void into the container saving the full amount of urine. Cleanse the labia using cleansing towels, position the container, and begin to void. Wipe the labia front to back with toilet paper and void into the sterile specimen container. Cleanse the labia using cleansing towels, begin to void into the toilet, and then collect the specimen.

Cleanse the labia using cleansing towels, begin to void into toilet, and then collect the specimen The client should cleanse the labia, begin to void, and then "catch" the sample midstream.

A client who underwent a kidney transplant 6 months earlier is seen in the clinic for a routine monthly appointment. The nurse reviews how the client has been doing and observes for signs/symptoms of acute rejection. Which signs/symptoms suggest acute rejection of the transplanted kidney? Select all that apply. Oliguria Swelling of the lips Tachypnea with wheezing Elevation of blood pressure over baseline Abdominal tenderness on the side of the kidney transplant Elevation of serum blood urea nitrogen (BUN) and creatinine

Elevation of blood pressure over baseline Abdominal tenderness on the side of the kidney transplant. Elevation of serum blood urea nitrogen (BUN) and creatinine. Oliguria Rationale: Acute rejection occurs 1 week to 2 years after a kidney transplant. Antibodies and white blood cells cause inflammation and vasculitis within the transplanted organ. Diagnosis is made by laboratory tests demonstrating impaired function of the organ and by changes in the donated organs found upon biopsy. Acute rejection is treated with increased immunosuppressant medication. Signs/symptoms of acute rejection of a transplanted kidney include abdominal tenderness over the transplanted kidney and decrease in organ function. Signs of decreased kidney function include oliguria (urine output between 100 and 400 mL in 24 hours), elevation in blood pressure, and elevation in the BUN and creatinine levels. Swelling of the lips is a sign of angioedema that occurs with an acute hypersensitivity reaction or anaphylaxis. Tachypnea (rapid breathing) with wheezing, the sound resulting from airway inflammation, occurs with many types of respiratory distress. It is not specific to acute rejection in a transplanted kidney.

A client with new-onset renal failure is having a first hemodialysis treatment. The nurse is especially careful to monitor the client for which signs/symptoms after the dialysis treatment? Hypertension, tachycardia, and fever Hypotension, bradycardia, and hypothermia Restlessness, irritability, and generalized weakness Headache, decreasing level of consciousness, and seizures

Headache, decreasing level of consciousness, and seizures Disequilibrium syndrome occurs most often in clients who are new to dialysis. It is characterized by headache, mental confusion, decreasing level of consciousness, nausea, vomiting, twitching, and possible seizure activity.

A client newly diagnosed with chronic kidney disease has recently begun hemodialysis. Which are signs/symptoms of disequilibrium syndrome?

Headache, deteriorating level of consciousness, and twitching. Disequilibrium syndrome is characterized by headache, mental confusion, decreasing level of consciousness, nausea and vomiting, twitching, and possible seizure activity. It is caused by the rapid removal of solutes from the body during hemodialysis.

The nurse is caring for a client diagnosed with Parkinson's disease who has prescribed benztropine mesylate daily. The nurse reinforces instructions to both the client and the spouse regarding the side effects of this medication and the need to report which side effect if it occurs? Inability to urinate Decreased appetite Shuffling, unsteady gait Irregular bowel movements

Inability to urinate Rationale: Urinary retention is a side effect of benztropine mesylate. The nurse should instruct the client or spouse about the need to monitor for difficulty with urinating, a distended abdomen, infrequent voiding in small amounts, and overflow incontinence. Options 2, 3, and 4 are unrelated to the use of this medication.

The nurse is evaluating the data results of a client with sepsis and acute kidney injury with related azotemia and oliguria. Which are the primary features of azotemia and oliguria? Select all that apply. Vasoconstriction Increase in cardiac output Increase in serum creatinine Increase in blood urea nitrogen (BUN) Urine output less than 0.5 mL/kg/hour Glomerular filtration rate (GFR) of 80 mL/min

Increase in serum creatinine Increase in blood urea nitrogen (BUN) Urine output less than 0.5 mL/kg/hour Rationale: Azotemia refers to an increase in serum creatinine and BUN, and oliguria is defined as a urine output less than 0.5 mL/kg/hour. Acute kidney injury with a decrease in GFR is often due to sepsis with related sepsis features. Vasodilation and a decrease in cardiac output occur with sepsis.

The nurse is providing dietary instructions to a client with renal calculi, and the laboratory analysis has revealed that the calculus is composed of uric acid. The nurse tells the client that it would be helpful to make which dietary changes? Increase intake of seafood in the diet. Increase intake of legumes in the diet. Include organ meat-type foods in the diet. Increase intake of cranberries and citrus fruits.

Increase intake of legumes in the diet. Dietary instructions to the client with a uric acid type kidney stone include increasing legumes, green vegetables, and fruits (except prunes, grapes, cranberries, and citrus fruits) to increase the alkalinity of the urine.

The nurse is reinforcing dietary instructions to a client diagnosed with acute glomerulonephritis. The nurse determines that the client understands the information presented if the client states the intention to do which action? Limit protein intake. Increase intake of high-fiber foods. Limit intake of magnesium-rich foods. Increase intake of potassium-rich foods.

Limit protein intake. The diet for the client with acute glomerulonephritis is generally high in calories and low in protein. This diet inhibits protein catabolism and allows the kidneys to rest. In acute glomerulonephritis, it is important to protect the kidneys while they are recovering their function.

A client, who had experienced significant blood loss in an automobile crash, was admitted to the hospital 2 days earlier. Does the nurse observe the client for which signs/symptoms indicate acute kidney injury (AKI)? Select all that apply. Hematuria Elevated urine specific gravity Severe spasmodic pain radiating to the groin area Rising serum blood urea nitrogen (BUN) and creatinine levels Urine output averaging 25 mL per hour while receiving an intravenous infusion at 150 mL/hour

Rising serum blood urea nitrogen (BUN) and creatinine levels Urine output averaging 25 mL per hour while receiving an intravenous infusion at 150 mL/hour. Elevated urine specific gravity Select all that apply. Rationale: Any condition that interrupts blood flow to the kidneys may cause AKI due to a prerenal etiology. Correcting fluid and blood deficits improves blood flow to the kidneys and prevents or treats AKI. Signs associated with AKI include low urinary output of concentrated urine (elevated specific gravity). The BUN and creatinine rise to levels above normal because the kidneys are not effective in clearing the waste products from the body. Hematuria and spasmodic pain are associated with urolithiasis. Hematuria occurs with multiple renal conditions including cancerous tumors in the urinary system and renal trauma.

A client, on the waiting list for a renal transplant, receives hemodialysis treatment. Which findings indicate to the nurse that the treatment has been effective? Select all that apply. A thrill is palpable in the arteriovenous fistula. The client states he is fatigued and wants to sleep. Serum potassium level is within the normal range. The client's weight is 2 kilograms less than the predialysis weight. Serum blood urea nitrogen (BUN) and creatinine levels are lower than predialysis.

Serum potassium level is within the normal range. The client's weight is 2 kilograms less than predialysis weight. Serum blood urea nitrogen (BUN) and creatinine levels are lower than predialysis. Rationale: The purpose of hemodialysis is to replace the client's kidney function. Hemodialysis removes waste products and excess fluid from the body and attains electrolyte balance. An effective hemodialysis treatment removes fluid resulting in a loss of weight. Body waste products are removed as reflected in a lower serum BUN and creatinine levels. Potassium is excreted by healthy kidneys, so a normal serum potassium level signifies that dialysis treatment is effective. Fatigue and a functioning arteriovenous fistula are normal findings but do not demonstrate that the dialysis treatment was effective in achieving kidney functions. In some clients, the hemodialysis procedure leads to fatigue, and clients prefer to rest after the treatment. A palpable thrill in the arteriovenous fistula signifies that the fistula has not clotted.

A client tells the nurse she completed an educational program to manage her stress incontinence but is now discouraged. Which information from the client indicates the need for further teaching? Select all that apply. She performs the Kegel exercises every other day. She maintains her fluid intake to 3000 mL of fluid daily. She quit drinking coffee with cream but drinks diet cola. She has decreased her caloric and fat intake to lose weight. She has begun an exercise program that includes lifting weights.

She performs the Kegel exercises every other day. She quit drinking coffee with cream but drinks diet cola. She has begun an exercise program that includes lifting weights. Rationale: With stress incontinence, the client loses a small amount of urine involuntarily during activities that increase abdominal pressure such as coughing, jogging, or lifting weights. This is due to weakened pelvic muscles and the inability to tighten the urethra enough to counteract bladder contraction. Kegel exercises in which the woman contracts and relaxes the pelvic muscles to regain muscle tone should be done on a daily basis and may take up to 3 months before yielding positive results. Clients should avoid caffeine and alcohol that stimulate bladder contraction. Diet cola likely contains caffeine. The exercise program involving weight lifting also increases abdominal pressure, leading to incontinence. The client is correct to lose weight (source for increased abdominal pressure) and maintaining adequate fluid intake.

A client is diagnosed with polycystic kidney disease, and the nurse provides information to the client about the treatment plan. Does the nurse determine that the client needs further teaching if the client states that which component is part of the treatment plan? Sodium restriction Genetic counseling Increased water intake Antihypertensive medications

Sodium restriction Individuals with polycystic kidney disease seem to waste rather than retain sodium. Thus, they need increased sodium and water intake. Aggressive control of hypertension is essential. Genetic counseling is advisable because of the hereditary nature of the disease.

The nurse is caring for a 58-year-old client with renal failure who is on peritoneal dialysis. Which finding is considered most important by the nurse, requiring health care provider notification? BUN: 40 mg/dL WBC 15,000 mm3 ECG: First-degree heart block Heart rate: 96 beats per minute

WBC 15,000 cells/mL. Peritonitis is the most common complication of peritoneal dialysis and is often caused by a contamination in the system. This infection can initially be determined by an increased WBC count. It can also include abdominal pain, cloudy peritoneal fluid, fever and chills, nausea and vomiting.

A client with acute pyelonephritis is scheduled for a voiding cystourethrogram. After the nurse provides information about this procedure, the client states, "I can't urinate in front of other people. I have a 'bashful' kidney." What is the nurse's best response? "Everyone feels that way." "The people there are all medical professionals." "You will be screened and given as much privacy as possible." "If you cannot urinate in front of others, the test will be canceled."

"You will be screened and given as much privacy as possible." Having to void in the presence of others can be very embarrassing for clients and actually may interfere with the client's ability to void. The nurse teaches the client about the procedure to try to minimize stress from lack of preparation and gives the client encouragement and emotional support. Screens may be used in the radiology department to try to provide an element of privacy during this procedure. Since a catheter was inserted to instill the dye, it could be left in place if the client is unable to urinate.

The nurse documents that the urine collected from a client diagnosed with early stage polycystic kidney disease is dilute with a low-specific gravity. Based on this documentation, which specific gravity result was likely present

1.000 Specific gravity is a measure of the concentration of particles in the urine. A normal range of urine specific gravity is approximately 1.005 to 1.030. Early in polycystic kidney disease, the ability of the kidneys to concentrate urine decreases.

A client with chronic kidney disease has been on dialysis for 3 years. The client is receiving the usual combination of medications for the disease, including aluminum hydroxide as a phosphate-binding agent. The client now has mental cloudiness, dementia, and complaints of bone pain. Which does this data indicate? Advancing uremia Phosphate overdose Folic acid deficiency Aluminum intoxication

Aluminum intoxication Occur when there is accumulation of aluminum, an ingredient in many phosphate-binding antacids. It results in mental cloudiness, dementia, and bone pain from infiltration of the bone with aluminum. This condition was formerly known as dialysis dementia.

A client diagnosed with chronic kidney disease is being treated at home with continuous ambulatory peritoneal dialysis. The client notes that there is a decrease in the catheter outflow following the prescribed 6-hour dwell time and calls the nurse to report this occurrence. The nurse should reinforce instructing the client to take which action? Ambulate in the home. Perform straight catheterization of the bladder. Immediately notify the primary health care provider. Flush the peritoneal catheter with a thrombolytic medication.

Ambulate in the home. The most common causes of decreased outflow of dialysate in peritoneal dialysis are displacement and obstruction of the catheter. Obstruction may be a result of malposition, adherence of the catheter tip to internal organs, constipation, or infection.

A male client has a history of urinary tract infections due to urinary retention. Which intervention should the nurse implement to decrease the risk of infection? Assist the client to stand for voiding. Withhold oral fluids after 6:00 pm daily. Ask the client to take his temperature daily. Teach the client to wash his hands properly.

Assist the client to stand for voiding. Most men are conditioned to urinate from a standing position, so a reasonable strategy is to assist the client to a standing position to increase the chance of emptying the bladder. This will decrease the risk of infection as the bladder empties more completely

The nurse monitoring a client receiving peritoneal dialysis notes that the client's outflow is less than the inflow. The nurse should take which actions? Select all that apply. Contact the nephrologist. Check the level of the drainage bag. Reposition the client to his or her side. Place the client in good body alignment. Check the peritoneal dialysis system for kinks. Increase the flow rate of the peritoneal dialysis solution.

Check the level of the drainage bag. Reposition the client to his or her side. Place the client in good body alignment. Check the peritoneal dialysis system for kinks.

The nurse is assisting a client with cystitis to select foods that are appropriate for an acid-ash diet. The nurse encourages the client to eat which food? Cheese Ice cream Garden peas Strawberries

Cheese Foods that are allowed on an acid-ash diet include meat, fish, shellfish, cheese, eggs, poultry, grains, cranberries, prunes, plums, corn, lentils, and foods with high amounts of chlorine, phosphorus, and sulfur.

A male client has a tentative diagnosis of urethritis. The nurse collects data from the client knowing that which are signs/symptoms of this disorder? Hematuria and pyuria Dysuria and proteinuria Hematuria and urgency Dysuria and penile discharge

Dysuria and penile discharge Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge

The nurse is caring for a client who has been diagnosed as having a kidney mass. The client asks the nurse the reason for a renal biopsy when other tests such as computed tomography (CT) and ultrasound are available. In formulating a response, the nurse incorporates the knowledge that a renal biopsy serves which purpose? Provides an outline of the renal vascular system Determines if the mass is growing rapidly or slowly Gives specific cytological information about the lesion Helps differentiate between a solid mass and a fluid-filled cyst

Gives specific cytological information about the lesion Renal biopsy is a definitive test that gives specific information about whether the lesion is benign or malignant. An ultrasound discriminates between a fluid-filled cyst and a solid mass.

The nurse is collecting data on a newly admitted client with a diagnosis of bladder cancer. Which sign/symptom should be noted first?

Hematuria Gross, painless hematuria is most frequently the first manifestation of bladder cancer. As the disease progresses, the client may experience dysuria, frequency, and urgency.

The nurse is reviewing the laboratory results and physical examination of a client with acute glomerulonephritis. Which data should the nurse see? Select all that apply. Polyuria Hematuria Proteinuria Hypotension Periorbital edema Decreased specific gravity

Hematuria Proteinuria Periorbital edema A client with acute glomerulonephritis usually becomes suddenly ill with fever, chills, flank pain, widespread edema, puffiness around the eyes, visual disturbances, and marked hypertension. Diagnosis is based on physical findings. The presence of marked hypertension is a late manifestation. Diagnostic tests include urinalysis, creatinine, blood urea nitrogen (BUN), and complete blood count (CBC). The urine may be smoky, will contain red blood cells and protein, output decreased and will have an increased specific gravity. Serum creatinine and BUN levels rise above normal. If the condition is severe, hematocrit and hemoglobin will indicate anemia.

The nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse notifies the registered nurse and plans to take which action? Stop the peritoneal dialysis. Institute hemodialysis temporarily. Obtain a culture and sensitivity of the drainage. Add antibiotics to the next several dialysis bags.

Obtain a culture and sensitivity of the drainage. When the drainage becomes cloudy, peritonitis is suspected. A culture and sensitivity is obtained, and broad-spectrum antibiotics are added to the dialysis solution as prescribed pending culture and sensitivity results.

The client with chronic kidney disease who is scheduled for hemodialysis this morning is due to receive a daily dose of enalapril (Vasotec). When should the nurse plan to administer this medication? During dialysis Just before dialysis The day after dialysis On return from dialysis

On return from dialysis Antihypertensive medications such as enalapril are given to the client following hemodialysis. This prevents the client from becoming hypotensive during dialysis and from having the medication removed from the bloodstream by dialysis

The nurse is reinforcing dietary instructions to a client who is currently prescribed probenecid. Which food should the nurse encourage the client to continue to eat? Liver Shrimp Spinach Scallops

Spinach Rationale: Probenecid inhibits the reabsorption of uric acid by the kidneys and promotes excretion of uric acid in the urine. Clients taking this medication are instructed to limit excessive purine intake. High-purine foods to avoid or limit include organ meats, sardines, scallops, anchovies, broth, mincemeat, herring, shrimp, mackerel, gravy, and yeast. Spinach is not a high-purine food.