Chapter 44: Assessment: Urinary System

A patient with suspected renal insufficiency is scheduled for a creatinine clearance diagnostic test. Which instructions would be appropriate for the nurse to provide to the patient?

"Empty your bladder and discard the urine; then save all urine for 24 hours." Rationale: The patient should discard the first urination when this test is started. Urine should be saved from all subsequent urinations for 24 hours. Creatinine clearance testing does not involve the injection of contrast dye. A serum creatinine is determined during the 24-hour period and used in the calculation to determine creatinine clearance. Consumption of a high-protein meal is not indicated. Sterile containers would be indicated if cultures are performed to determine the presence of microorganisms.

The nurse is caring for an older adult patient taking bumetanide. What age-related changes does the nurse inform the patient may be experienced?

Decreased function of the loop of Henle Rationale: Bumetanide (Bumex) is a loop diuretic that acts in the loop of Henle to decrease reabsorption of sodium and chloride. Because the loop of Henle loses function with aging, the excretion of drugs becomes less and less efficient. Thus, the circulating levels of drugs are increased and their effects prolonged. The benign enlargement of prostatic tissue, decreased sensation of bladder capacity, and loss of concentrating ability do not directly affect the action of loop diuretics.

A patient has sought care because of recent difficulties in establishing and maintaining a urine stream as well as pain that occasionally accompanies urination. How should the nurse document this abnormal assessment finding?

Dysuria Rationale: Painful and difficult urination is characterized as dysuria. Whereas anuria is an absence of urine production, oliguria is diminished urine production. Enuresis is involuntary nocturnal urination.

patient was admitted 2 weeks ago after multiple traumatic injuries in a motor vehicle collision. The patient now has a serum creatinine at 3.9 mg/dL and blood urea nitrogen (BUN) of 100 mg/dL. Which medication, if ordered by the health care provider, should the nurse question?

Gentamicin Rationale: Elevated serum creatinine and BUN indicate renal insufficiency or acute kidney injury. All medications should be evaluated for nephrotoxic potential. Many drugs are known to be nephrotoxic (see Table 44.3); gentamicin is a potential nephrotoxic agent.

In addition to urine function, the nurse recognizes that the kidneys perform numerous other functions important to maintaining homeostasis. Which physiologic processes are performed by the kidneys? (Select all that apply.)

Release of renin Activation of vitamin D Erythropoietin production Rationale: In addition to urine formation, the kidneys release renin to maintain blood pressure, activate vitamin D to maintain calcium levels, and produce erythropoietin to stimulate RBC production. Carbohydrate metabolism and hemolysis of old RBCs are not physiologic functions that are performed by the kidneys.

The nurse obtained a urine specimen from a patient. What result should the nurse recognize as an abnormal finding?

White blood cells (WBCs) 9/hpf Rationale: Normal WBC levels in urine are below 5/hpf, with levels exceeding this indicative of inflammation or urinary tract infection. A urine pH of 6.0 is average; amber yellow is normal coloration, and the reference range for specific gravity is 1.003 to 1.030.

What glomerular filtration rate (GFR) would the nurse estimate for a 30-yr-old patient with a creatinine clearance result of 60 mL/min?

a. 60 mL/min

How will the nurse assess for flank tenderness in a patient with suspected pyelonephritis?

b. Strike a flat hand covering the costovertebral angle (CVA) Checking for flank pain is performed by percussion of the CVA and asking about pain. The other techniques would not assess for flank pain.

A patient gives the admitting nurse health information before a scheduled intravenous pyelogram (IVP). Which item requires the nurse to intervene before the procedure?

b. The patient lists allergies to shellfish and penicillin Iodine-based contrast dye is used during IVP and for many CT scans. The nurse will need to notify the health care provider before the procedures so that the patient can receive medications such as antihistamines or corticosteroids before the procedures are started. The other information does not have immediate implications for the patient's care during the procedures.

The nurse prepares a patient for discharge after a cystoscopy. It is most important for the nurse to provide additional information in response to which patient statement?

"Bright red bleeding is normal for a few days after the procedure." Rationale: Bright red bleeding after a cystoscopy is not normal and should be reported immediately. Other complications include urinary retention, bladder infection, and perforation of the bladder. Patients should drink plenty of fluids and expect burning on urination, pink-tinged urine, and urinary frequency. Warm sitz baths, heat, and mild analgesics may be used to relieve discomfort.

A patient tells the nurse that they are having burning on urination, dysuria, and frequency. What is the best response by the nurse?

"Come in so we can check a clean-catch urine specimen." Rationale: The patient's symptoms are typical of a urinary tract infection. To verify this, a clean-catch urine specimen must be obtained for a specimen of urine to culture. Drinking less fluid will not improve the symptoms. Acetaminophen would not decrease the discomfort; an antibiotic would be needed. Avoiding caffeine and spicy food may decrease bladder inflammation but will not affect these symptoms.

The nurse is caring for a hospitalized patient with a decreased glomerular filtration rate who is scheduled for an intravenous pyelogram (IVP). Which action will be included in the plan of care?

. Monitor the urine output after the procedure. Patients with impaired renal function are at risk for decreased renal function after IVP because the contrast medium used is nephrotoxic, so the nurse should monitor the patient's urine output. MAC sedation and retention catheterization are not required for the procedure. The contrast medium is given IV, not orally.

The nurse is preparing a patient for an intravenous pyelogram (IVP). What is a priority action by the nurse?

Administer a cathartic or enema. Rationale: Nursing responsibilities in caring for a patient undergoing an IVP include administration of a cathartic or enema to empty the colon of feces and gas. The nurse will also assess the patient for iodine sensitivity; keep the patient NPO for 8 hours before the procedure; and advise the patient that warmth, a flushed face, and a salty taste during injection of contrast material may occur.

A postoperative patient had a urinary catheter. Eight hours after catheter removal and drinking fluids, the patient has not been able to void. What is the nurse's first action to assess for urinary retention?

Bladder scan Rationale: If the patient is unable to void, the bladder may be palpated for distention or percussed for dullness if it is full, or a bladder scan may be done to determine the approximate amount of urine in the bladder. A cystometrogram visualizes the bladder and evaluates vesicoureteral reflux. A KUB x-ray delineates size, shape, and positions of kidneys and possibly a full bladder. Neither of these would be useful in this situation. A residual urine test requires urination before catheterizing the patient to determine the amount of urine left in the bladder, so this assessment would not be helpful for this patient.

A patient in the intensive care unit is receiving gentamicin for treatment of pneumonia from Pseudomonas aeruginosa. What assessment results should the nurse report to the health care provider?

Elevated creatinine level Rationale: Gentamicin can be toxic to the kidneys and the auditory system. The elevated creatinine level must be reported to the provider because it probably indicates renal damage. Other factors that may occur with renal damage would include increased weight and decreased urinary output. Many medications have side effects of anorexia.

The nurse is caring for a patient after a right kidney biopsy. Which position would be the most appropriate for this patient immediately after the procedure?

Right lateral side-lying position Rationale: After a renal biopsy, a pressure dressing should be applied. The patient should be kept on the affected side for 30 to 60 minutes to apply additional pressure from the patient's own body weight and then on bed rest for 24 hours. High Fowler's position with arms supported is a position for a patient in respiratory distress. Reverse Trendelenburg position is used to maintain circulation to the legs in peripheral artery insufficiency. Supine with legs elevated puts excessive pressure on the diaphragm and should generally be avoided.

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) admitted for pneumonia. What laboratory finding would be consistent with decreased kidney function?

Serum creatinine 2.3 of mg/dL Rationale: An expected assessment finding related to decreased kidney function in the aging process is an increased serum creatinine. Other expected assessments include an elevated BUN and inability to concentrate urine (with urine specific gravity fixed at 1.010). Uric acid is used as a screening test for disorders of purine metabolism or kidney disease; values depend on renal function, rate of purine metabolism, and dietary intake of food rich in purines. Normal reference intervals: serum creatinine, 0.6 to 1.3 mg/dL; BUN, 6 to 20 mg/dL; urine specific gravity, 1.003 to 1.030; and serum uric acid, 2.3 to 6.6 mg/dL (female) or 4.4 to 7.6 mg/dL (male).

The nurse is performing an assessment for a patient and preparing to palpate the kidneys. How should the nurse position the patient for this assessment?

Supine Rationale: To palpate the right kidney, the patient is positioned supine, and the nurse's left hand is placed behind and supports the patient's right side between the rib cage and the iliac crest. The right flank is elevated with the left hand, and the right hand is used to palpate deeply for the right kidney. The normal-sized left kidney is rarely palpable because the spleen lies directly on top of it.

When a patient reports acute, severe, renal colic pain in the lower abdomen, the nurse suspects that the patient is most likely to have an obstruction at which area?

Ureterovesical junction Rationale: The ureterovesical junction is the narrowest part of the urethra and easily obstructed by urinary calculi. With a stone in the kidney or at the ureteropelvic junction, the pain may be dull costovertebral flank pain. Stones in the bladder do not cause obstruction or symptoms unless they are staghorn stones. The urethra seldom has obstruction related to stones.

A patient with a history of recurrent urinary tract infections has been scheduled for a cystoscopy. What teaching point should the nurse emphasize before the procedure?

You might have pink-tinged urine and burning after your cystoscopy." Rationale: Pink-tinged urine, burning, and frequency are common after a cystoscopy. The patient does not need to be NPO before the test, and contrast media is not needed. A cystoscopy does not always necessitate catheterization before or after the procedure.

A female patient being admitted with pneumonia has a history of neurogenic bladder due to a spinal cord injury. Which action will the nurse plan to take first?

a. Ask about the usual urinary pattern and any measures used for bladder control.

A patient who has increased blood urea nitrogen (BUN) and serum creatinine levels is scheduled for a renal arteriogram. Which bowel preparation order would the nurse question for this patient?

a. Fleet enema High-phosphate enemas, such as Fleet enemas, should be avoided in patients with elevated BUN and creatinine because phosphate cannot be excreted by patients with renal failure. The other medications for bowel evacuation are more appropriate.

Which medication taken by a patient with decreased renal function will be of most concern to the nurse?

a. ibuprofen (Motrin) Nonsteroidal antiinflammatory medications (NSAIDs) are nephrotoxic and should be avoided in patients with impaired renal function. The nurse should also ask about reasons the patient is taking the other medications, but the medication of most concern is the ibuprofen

The nurse completing a physical assessment for a newly admitted patient is unable to feel either kidney on palpation. Which action should the nurse take?

b. Document the information on the assessment form. The kidneys are protected by the abdominal organs, ribs, and muscles of the back and may not be palpable under normal circumstances. No action is needed except to document the assessment information.

A 78-yr-old patient has been admitted with benign prostatic hyperplasia. What is most appropriate to include in the nursing plan of care?

b. Leave a light on in the bathroom during the night. The patient's age and diagnosis indicate a likelihood of nocturia, so leaving the light on in the bathroom is appropriate. Fluids should be encouraged because dehydration is more common in older patients. The information in the question does not indicate that measurement of the patient's output is necessary or that the patient has overflow incontinence.

A female patient with a suspected urinary tract infection is to provide a clean-catch urine specimen for culture and sensitivity testing. What should the nurse do to obtain the specimen?

b. Tell the patient to clean the urethral area, void a small amount into the toilet, then void directly into a sterile container This answer describes the technique for obtaining a clean-catch specimen. The answer beginning, "insert a short, small, 'mini' catheter attached to a collecting container" describes a technique that would result in a sterile specimen, but a health care provider's order for a catheterized specimen would be required. Using Betadine before obtaining the specimen might result in suppressing the growth of some bacteria. The technique described in the answer beginning "have the patient empty the bladder completely" would not result in a sterile specimen.

When caring for a patient after cystoscopy, what should the nurse include in the plan of care?

b. The patient understands to expect blood-tinged urine. Pink-tinged urine and urinary frequency are expected after cystoscopy. Burning on urination is common, but pain that requires opioids for relief is not expected. A good fluid intake is encouraged after this procedure. Bed rest is not required after cystoscopy.

A patient passing bloody urine has scheduled a cystoscopy with cystogram. Which description of the procedure by the nurse is accurate?

c. "Your doctor will insert a lighted tube in the bladder through your urethra, inspect the bladder, and instill dye to outline your bladder on x-ray." In a cystoscope and cystogram procedure, a cystoscope is inserted into the bladder for direct visualization, and then contrast solution is injected through the scope so that x-rays can be taken. The response beginning, "Your doctor will place a catheter" describes a renal arteriogram procedure. The response beginning, "Your doctor will inject a radioactive solution" describes a nuclear scan. The response beginning, "Your doctor will insert a lighted tube into the bladder, and little catheters will be inserted" describes a retrograde pyelogram.

Which nursing action is essential for a patient immediately after a renal biopsy?

c. Apply a pressure dressing and position the patient on the affected side. A pressure dressing is applied, and the patient is kept on the affected side for 30 to 60 minutes to put pressure on the biopsy side and decrease the risk for bleeding. The blood glucose and BUN/creatinine will not be affected by the biopsy. Although monitoring for hematuria is needed, there is no need for catheterization.

A male patient in the clinic provides a urine sample that is red-orange in color. Which action should the nurse take?

c. Ask the patient about current medications. A red-orange color in the urine is normal with some over-the-counter (OTC) medications such as phenazopyridine. The color is not expected with urinary tract infection, is not a sign that poor technique was used in obtaining the specimen and does not need to be communicated to the health care provider until further assessment is done.

The nurse is examining an adult patient. For what purpose would the nurse use palpation?

c. Checking for bladder distention A distended bladder may be palpable above the symphysis pubis. Palpation would not be helpful in assessing for the other listed urinary tract information.

What action should the nurse take first when a patient's urine dipstick test indicates a small amount of protein?

c. Inquire about which medications the patient is currently taking. Normally the urinalysis will show zero to trace amounts of protein, but some medications may give false-positive readings. The other actions by the nurse may be appropriate but checking for medications that may affect the dipstick accuracy should be first.

Which information from a patient's urinalysis requires that the nurse notify the health care provider?

c. WBC 20 to 26/hpf

1. Which question should the nurse ask to assess a patient's dysuria?

d. "Do you have pain when you urinate?" ANS: D Dysuria is painful urination. The alternate responses can be used to assess other urinary tract symptoms: hematuria, nocturia, and frequency.

Which statement by a patient who had a cystoscopy the previous day should the nurse report immediately to the health care provider?

d. "My temperature is 101." The patient's elevated temperature may indicate a bladder infection, a possible complication of cystoscopy. The health care provider should be notified so that antibiotic therapy can be started. Pink-tinged urine is expected after a cystoscopy. The insomnia and bruising should be discussed further with the patient but do not indicate a need to notify the health care provider.

A young adult employed as a hair stylist who has a 15 pack-year history of cigarette smoking arrives for an annual physical examination. Which area of increased risk should the nurse plan to teach the patient?

d. Bladder cancer Exposure to the chemicals involved with working as a hair stylist and in smoking both increase the risk of bladder cancer, and the nurse should assess whether the patient understands this risk. The patient is not at increased risk for renal failure, pyelonephritis, or kidney stones.

A hospitalized patient who has possible renal insufficiency after coronary artery bypass surgery will have a creatinine clearance test. Which item will the nurse need to obtain?

d. Large urine container Because creatinine clearance testing involves a 24-hour urine specimen, the nurse should obtain a large container for the urine collection. Catheterization, cleaning of the perineum with antiseptic towelettes, and a sterile specimen cup are not needed for this test.

When working in the urology/nephrology clinic, which patient's care could the nurse delegate to an experienced licensed practical/vocational nurse (LPN/VN)?

d. Patient who will have catheterization to check for residual urine after voiding. LPN/VN education includes common procedures such as catheterization of stable patients. The other patients require complex assessments or patient teaching that are included in registered nurse (RN) education and scope of practice.

In the accompanying figure, what is the nurse assessing via percussion?

d. Upper urinary tract inflammation The nurse in the photo is using indirect percussion to determine the presence or absence of costovertebral angle (CVA) tenderness, which suggests pyelonephritis or polycystic kidney disease. The liver size would be percussed from the anterior direction with the patient positioned supine. Chest stability and excursion are determined by palpating and observing for symmetry of expansion. Pulmonary tissue density would be determined by tapping the interphalangeal joint over the lung fields and listening for resonance.