2021 HESI - GU
Which goal would the nurse establish when providing care for a client recovering from a transurethral resection of the prostate (TURP)? A-Maintain patency of the cystostomy tube. B-Prevent wound hemorrhage and infection. C- Maintain patency of the indwelling catheter. D-Prevent the abdominal dressing from draining.
-C -Indwelling catheter patency promotes bladder decompression, which prevents distention and bleeding; continuous flow of an irrigant limits clot formation and promotes hemostasis. Maintaining patency of the cystostomy tube is not associated with a TURP; a cystostomy tube is a catheter that is placed directly into the bladder through a suprapubic incision. No abdominal incision is made because the resection is performed via the urethra. Although hemorrhage and infection may occur, no wound is observed because the surgery was performed via the urethra.Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action.
An ambulatory client with benign prostatic hyperplasia reports to the morning nurse his inability to void all night long. Upon assessment, the nurse identifies distention of the client's bladder. Which action would the nurse implement? A-Ask him to use a urinal. B-Encourage increased fluids. C-Assist him into a warm shower. D-Exert pressure over the pubic area.
-C -Warm water often will relax the urinary sphincter, enabling a client to void. The client already indicated an inability to void, so asking him to use a urinal is inappropriate; plus, the client is ambulatory, able to stand, and go to the bathroom, which is a more natural method than the urinal. The distended bladder indicates adequate fluid intake, increasing fluid intake will increase pressure and may result in hydronephrosis. Pressure over a distended bladder induces pain, which causes muscular contraction of the urinary sphincter.Test-Taking Tip: These statements are crucial requisites for performing well on the NCLEX exam: (1) A sound understanding of the subject; (2) The ability to follow explicitly the directions given at the beginning of the test; (3) The ability to comprehend what is read; (4) The patience to read each question and set of options carefully before deciding how to answer the question; (5) The ability to use the computer correctly to record answers; (6) The determination to do well; (7) A degree of confidence.
A client reports urinary frequency and burning. Which area would the nurse assess for indicators of an ascending urinary tract infection? A-Tail of Spence B- Suprapubic area C- McBurney point D- Costovertebral angle
-D- Costoverterbral angle -The costovertebral angle (the angle formed by the lateral and downward curve of the lowest rib and the vertebral column of the spine itself) is percussed to determine whether there is tenderness in the area over the kidney; this can be a sign of glomerulonephritis or severe upper urinary tract infection.
Which manifestations are specifically associated with urinary system disorders? Select all that apply. One, some, or all responses may be correct. 1-Facial edema 2-Excessive thirst 3-Stress incontinence 4-Nausea and vomiting 5-Elevated blood pressure
-Facial edema and stress incontinence -The specific manifestations associated with urinary system disorders include facial edema and stress incontinence. The general manifestations associated with urinary system disorders include excessive thirst, nausea and vomiting, and elevated blood pressure.
Which technique would the nurse use to obtain a culture specimen of discharge from the penis? A-Instruct the client to provide a semen specimen. B-Swab the discharge from the prepuce. C-Instruct the client to obtain a clean-catch specimen of urine. D-Swab the drainage directly from the urethra.
- D -Swabbing the drainage directly from the urethra obtains a specimen uncontaminated by environmental organisms. Instructing the client to provide a semen specimen is not as accurate as obtaining the purulent discharge from the site of origin. Swabbing the discharge when it appears on the prepuce will contaminate the specimen with organisms external to the body. Teaching the client how to obtain a clean-catch specimen of urine will dilute and possibly contaminate the specimen.
A client with end-stage renal disease states, "I heard that it is inevitable that I will need a kidney transplant. If so, which one of my kidneys will be removed?" Which response would the nurse use to reply to the client's question? A-"Neither of your kidneys will be removed unless they become infected." B-"The kidney that is the most diseased is removed and replaced with a new one." C-"Your primary health care provider determines which kidney is replaced with a new one." D-"Your right kidney will be removed, because it has a longer renal vein, making transplantation easier."
-A -During a renal transplant, removal of the recipient's own kidneys does not occur unless a chronic infection is present. The primary health care provider will not decide which kidney is replaced, the most diseased kidney will not be removed, and the right kidney will stay because the kidneys are left in place; the new kidney is placed in the right lower quadrant and protected by the iliac crest.
A client who is 5 feet 8 inches tall (173 cm) and weighs 220 lb (99.8 kg) has ureteral colic, blood in the urine, and a blood pressure (BP) of 150/90 mm Hg. Which objective is has the highest priority and directs the nursing interventions for this client? A-Decrease pain B-Decrease weight C-Decrease hematuria D-Decrease hypertension
-A -Ureteral colic clinical manifestations include sharp, severe pain (renal colic) radiating toward the genitalia and thigh. It is associated with ureteral distention and must be relieved. Weight loss is a long-term goal; reducing pain is the priority. Although the hematuria is a concern and is caused by the renal calculi, pain reduction is the priority. Although the client's hypertension is a concern, pain reduction is the priority. The BP will decrease with a reduction in the pain.
After receiving reports on four clients who are postnephrostomy tube placement, which client would the nurse see first? A-The client with tenderness at the surgical site B-The client with small clots in the drainage bag C-The client with cloudy urine in the drainage bag D-The client requesting the next dose of pain medication
-C -The client with cloudy urine could have an infection that should be evaluated for accompanying symptoms like fever and back pain and reported immediately to the surgeon. Tenderness at the surgical site is expected and not a priority over cloudy urine. Small clots in the urine collection bag are expected and not a priority over cloudy urine in the bag. The client requesting pain medication should be attended to soon, but the cloudy urine must be first assessed and reported.Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low-fat, high-protein, low-calorie diet).
Which action would the nurse include when developing a postprocedure plan of care for a client with continuous bladder irrigations after a transurethral vaporization of the prostate? A-Measure the output hourly and monitor total output trends. B-Monitor the specific gravity of the urine each shift. C-Irrigate the triple-lumen catheter with normal saline three times daily. D-Deduct the amount of instilled irrigant from the total output.
-D -The amount of irrigant instilled into the bladder must be deducted from the total output to determine the amount of urine produced. The client will have an indwelling catheter, and hourly measurements are not possible because the irrigant is mixing with the urine. Abnormal specific gravity values are not associated with this procedure and would be inaccurate because the irrigant is mixing with the urine. Because the bladder is being irrigated continuously, no additional irrigations are needed.Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation.