Kidney Disorders and Therapeutic Management (Urden ch. 26)

The nurse is instructing an older adult female client about interventions to decrease the risk for cystitis. Which client comment indicates that the teaching was effective? "I must avoid drinking carbonated beverages." "I need to douche vaginally once a week." "I need to drink 2½ liters of fluid every day." "I will not drink fluids after 8 PM each evening."

"I need to drink 2½ liters of fluid every day." - Teaching an older female about interventions to decrease the risk for cystitis is effective when the client says, "I need to drink 2½ liters of fluid every day." *Drinking this much fluid each day flushes out the urinary system and helps reduce the risk for cystitis.* - Avoiding carbonated beverages is NOT necessary to reduce the risk for cystitis. - Douching is not a healthy behavior because it removes beneficial organisms as well as the harmful ones. - *Avoiding fluids after 8:00 p.m. would help prevent nocturia but NOT cystitis.* It is recommended that clients with incontinence problems limit their late-night fluid intake to 120 mL.

A client is admitted for extracorporeal shock wave lithotripsy (ESWL). What information obtained on admission is most critical for a nurse to report to the primary health care provider before the ESWL procedure begins? "Blood in my urine has become less noticeable, so maybe I don't need this procedure." "I have been taking cephalexin (Keflex) for an infection." "I previously had several ESWL procedures performed." "I take over-the-counter naproxen (Aleve) twice a day for joint pain."

"I take over-the-counter naproxen (Aleve) twice a day for joint pain." - For a client admitted for ESWL, it is most critical for the nurse to report to the primary health care provider that the client takes over-the-counter naproxen twice a day for joint pain. *Because a high risk for bleeding during ESWL has been noted, clients would NOT take nonsteroidal antiinflammatory drugs before this procedure.* The ESWL will have to be rescheduled for this client. - Blood in the client's urine would be reported to the primary health care provider but will not require rescheduling of the procedure because blood is frequently present in the client's urine when kidney stones are present. A diminished amount of blood would not eliminate the need for the procedure. - The client's taking cephalexin (Keflex) and the fact that the client has had several previous ESWL procedures would be reported, but will not require rescheduling of the procedure.

A client who was previously diagnosed with a urinary tract infection (UTI) and started on antibiotics returns to the clinic 3 days later with the same symptoms. When asked about the previous UTI and medication regimen, the client states, "I only took the first dose because after that, I felt better." How does the nurse respond? "Not completing your medication can lead to return of your infection." "That means your treatment will be prolonged with this new infection." "This means you will now have to take two drugs instead of one." "What you did was okay; however, let's get you started on something else."

"Not completing your medication can lead to return of your infection." - The nurse tells the client with a UTI who only took the first dose of a 3-day prescription that, "not completing your medication can lead to return of your infection." *Not completing the drug regimen can lead to recurrence of an infection and bacterial drug resistance.* - Needing to be retreated does NOT mean that the client will have a prolonged treatment regimen. - Some treatment modalities are given over a 3-day period. Given this client's history, larger doses for a shorter time span may be a wise plan. - The client does not need to take two drugs, and this response is punitive rather than instructive. - Saying that the client's actions were okay does not inform the client with respect to nonadherence. The client needed to take all the prescribed medication to make certain that the infection was properly treated.

Urethral Stricture (What it is, s/s, what it causes, treatment) *(Urethroplasty)*

*Urethroplasty:* stent placement in the urethra or reconstruction to allow for proper outflow of urine.

Chronic glomerulonephritis (Assessment)

- *Chronic glomerulonephritis develops over YEARS to DECADES.* - Mild proteinuria and hematuria, hypertension, fatigue, and occasional edema are often the only symptoms. - The loss of nephrons reduces glomerular filtration. Hypertension and renal arteriole sclerosis are often present. The glomerular damage allows proteins to enter the urine. Chronic glomerulonephritis always leads to end-stage kidney disease (ESKD)

Cystitis (s/s, diagnosed, management)

- *Cystitis is an inflammatory condition of the BLADDER.* In some cases, Cystitis can be caused by inflammation WITHOUT infection. *For example, drugs, chemicals, or local radiation therapy cause bladder inflammation without an infecting organism.* Female hygiene products may cause inflammation as well.

PKD: Etiology and Genetic Risk ; Interventions *(Autosomal dominant vs recessive)*

- *There is NO way to prevent PKD, although early detection and management of hypertension may slow the progression of kidney damage and impaired ELIMINATION.* Genetic counseling may be useful for adults who have one parent with PKD. *Autosomal Dominant is the most common cause of PKD. The cysts start to form around age 30 ; Autosomal Recessive means the cysts are present at birth, and they usually die as children.* - Hypertension control is the #1 nursing priority!

Etiology and genetic risk of UTI

- *With UTI, bacteria move up the urinary tract from the external urethra to the bladder to cause infectious cystitis.* - *About 90% of UTIs are caused by Escherichia coli. Catheters* are the most common factor associated with new-onset UTIs in the hospital and long-term care settings - *Within 48 hours of catheter insertion, bacterial colonization along the urethra and the catheter itself begins. About half of patients with indwelling catheters become infected within 1 week of catheter insertion.*

Bladder Trauma (*2 common signs*) *(Post op patients will require a ___)*

- Bladder trauma can be caused by *penetrating or blunt injury to the lower abdomen.* Penetrating injury may occur by stabbing, gunshot wound, or other trauma in which objects pierce the abdominal wall. - Patients with a penetrating bladder wound often have *anuria or hematuria.* - Patients with an anterior bladder wall injury usually have a *Penrose drain and a Foley catheter in place after surgery.* In some instances, vaginal or rectal fistulas may also require repair. - Psychosocial support is critical for patients who have sustained traumatic injuries. Refer them to counseling resources to help them deal with psychosocial issues.

Management of Pyelonephritis (Drugs used, pyelolithotomy, nephrectomy)

- Drug therapy can reduce pain. *Acetaminophen is preferred over NSAIDs because it does not interfere with kidney autoregulation of blood flow.* Reduction of fever will also reduce pain. Some patients may require the use of opioids in the short term for pain control. - Drug therapy with antibiotics is prescribed to treat the infection. At first the antibiotics are broad spectrum. After urine and blood culture and sensitivity results are known, more specific antibiotics may be prescribed - The surgical procedures may be one of these: *pyelolithotomy (stone removal from the kidney), nephrectomy (removal of the kidney),* ureteral diversion, or reimplantation of ureter(s) to restore proper bladder drainage. - A pyelolithotomy is needed for removal of a large stone in the kidney pelvis that blocks urine flow and causes infection. Nephrectomy is a last resort when all other measures to clear the infection have failed. For patients with poor ureter valve closure or dilated ureters, *ureteroplasty (ureter repair or revision)* or ureteral reimplantation (through another site in the bladder wall) preserves kidney function and eliminates infections.

5 Stages of CKD *(Normal GFR range)*

- In the first stage, the patient may have a *normal GFR (greater than 90 mL/min)* but have abnormal urine findings, structural abnormalities, or genetic traits that point to kidney disease. - In Stage 2 CKD, GFR is reduced, ranging between 60 and 89 mL/min, and albuminuria may be present. - In Stage 3 CKD, GRF reduction continues and ranges between 30 and 59 mL/min, and albuminuria is usually present. - Over time, patients progress to Stage 4 CKD and end-stage kidney disease (ESKD) (Stage 5). Waste ELIMINATION is poor with excessive amounts of urea and creatinine building up in the blood, and the kidneys cannot maintain homeostasis. Severe impairments of FLUID AND ELECTROLYTE BALANCE and ACID-BASE BALANCE occur. Without kidney replacement therapy, death results from ESKD.

Nephrosclerosis (greatest risk factor)

- Nephrosclerosis is a degenerative disorder resulting from changes in kidney blood vessels. *Nephron blood vessels thicken, resulting in narrowed lumens and decreased kidney blood flow.* The tissue is *chronically hypoxic,* with ischemia and fibrosis developing over time. - *Hypertension is the greatest risk factor!* Nephrosclerosis occurs with all types of hypertension, atherosclerosis, and diabetes mellitus. *The more severe the hypertension, the greater the risk for severe kidney damage.* (should be <160/110) - Management focuses on *controlling high blood pressure and reducing albuminuria to preserve kidney function.* - ACEIs and Diuretics are often prescribed.

Renovascular Disease *(What it is, causes, s/s)* *(How is it diagnosed?)* *(Sudden increase in what?)*

- Renovascular disease is a progressive condition that causes *narrowing or blockage of the renal arteries or veins. These are the blood vessels that take blood to and from the kidneys.* - Uncorrected renovascular disease, such as *renal vein thrombosis or renal artery stenosis, atherosclerosis, or thrombosis, causes ischemia and atrophy of kidney tissue, leading to severe impairment of urinary ELIMINATION, FLUID AND ELECTROLYTE BALANCE, and ACID-BASE BALANCE.* - Patients with renovascular disease, particularly those older than 50 years of age, often have a *SUDDEN ONSET of HYPERTENSION from this disease.* - *Atherosclerotic* changes in the renal artery often occur along with sclerosis in the *aorta* and other major vessels. *Fibrotic changes of the blood vessel wall occur throughout the length of the renal artery.* - Diagnosis is made by magnetic resonance angiography (MRA). *MRA provides an excellent image of the renal vasculature and kidney anatomy.*

Functions of Dialysis (4)

- Rids the body of excess fluids and electrolytes. - Achieves an acid-base balance - Eliminates waste products - Restores internal homeostasis by osmosis, diffusion, and ultrafiltration

Glomerulonephritis *(Glomerulus function ; why can anemia occur?)* *(Usually preceded by what type of infection?)*

- The glomerulus works to filter blood. *Inflamed glomeruli allow passage of protein and blood in the urine.* - Glomerulonephritis is associated with *high blood pressure, progressive kidney damage (leading to CKD), and edema.* - *Anemia from reduced production of erythropoietin* and high cholesterol often co-occur. Glomerulonephritis can cause altered urinary ELIMINATION.

Uremic frost (BUN levels ; Caused by)

- Urea and uric acid salt deposits excreted in sweat as a result of uremia, giving the skin a powdery appearance - This dermatological manifestation of severe *azotemia* is rarely seen today because of early dialytic intervention.

S/S of Chronic Pyelonephritis (hint: hypers)

- Urinalysis shows a positive leukocyte esterase and nitrite dipstick test and the presence of white blood cells (WBCs) and bacteria. Occasional red blood cells and protein may be present.

Which clients with an indwelling urinary catheter does the nurse reassess to determine whether the catheterization needs to be continued or can be discontinued? Select all that apply. Three-day postoperative client client in the step-down unit Comatose client with careful monitoring of intake and output (I&O) Incontinent client with perineal skin breakdown Incontinent older adult in long-term care

1,2,5 - To decide whether the catheterization needs to be continued or discontinued, the nurse reassesses the *3-day postoperative client, the client in the step-down unit, and the incontinent older adult in long-term care.* - Three days after surgery, the postoperative client probably would be able to urinate on his or her own. This may be influenced by the type of surgery, but *most clients do not need long-term catheterization after they have surgery.* - *The incidence of complications (colonization of bacteria) begins to increase after 48 hours post-insertion.* The client in the step-down unit is definitely one who would be considered for catheter discontinuation. He or she would be somewhat ambulatory and able to get to a bedside commode. - Incontinence in older adults does not necessarily mean that they have to be catheterized. The introduction of a catheter invites the possibility of infection. *These clients can often be managed with adult incontinence pads with less risk for developing a urinary tract infection.* These infections in the older adult population are serious and would be avoided. - The comatose client who is on strict I&O must have a urinary catheter in place to keep an accurate account of fluid balance. - A client who is incontinent with no breakdown areas would be considered, but perineal skin problems in this situation make a catheter necessary for this client's skin to have a clean, dry environment for healing.

The nurse in the urology clinic is providing teaching for a female client with cystitis. Which instructions does the nurse include in the teaching plan? *Select all that apply.* Cleanse the perineum from back to front after using the bathroom. Try to take in 64 ounces (2 liters) of fluid each day. Be sure to complete the full course of antibiotics. If urine remains cloudy, call the clinic. Expect some flank discomfort until the antibiotic has worked.

2,3,4 - In the teaching plan for a female clinic client with cystitis, the nurse tells the client: *try to take in 64 ounces (2 liters) of fluid every day, be sure to complete the full course of antibiotics, and call the clinic if the urine remains cloudy.* Between 64 and 100 ounces (2 to 3 liters) of fluid would be taken daily to dilute bacteria and prevent infection. Not completing the course of antibiotics could suppress the bacteria but would not destroy all bacteria, causing the infection to resurface.* For persistent symptoms of infection, the client would contact the primary health care provider.* - The perineal area needs to be cleansed from front to back or "clean to dirty" to prevent infection. Cystitis produces suprapubic symptoms. *Flank pain occurs with infection or inflammation of the KIDNEY.*

When providing care to a client who has undergone a nephrotomy for hydronephrosis, which observation alerts the nurse to a possible complication? *Select all that apply.* A. Urine output of 15 mL for the first hour and then diminished B. Tenderness at the surgical site C. Pink-tinged urine draining from the nephrostomy D. A hematocrit value 3% lower than the preoperative value E. Sudden onset of abdominal pain that worsens after abdominal palpation F. Blood pressure of 180/90 that persists despite administration of pain medication G. The presence of a few small (less than 0.5 cm) clots with irrigation of the nephrostomy H. Bright red drainage through the nephrostomy tube 12 hours after the procedure

A, D, E, F, H - *Low output is concerning immediately after nephrostomy placement; most clients have a diuresis.* - After nephrostomy placement, most clients have bloody urine (red- or pink-tinged) for several hours. - *Irrigation may be required to maintain patency and clots may be dislodged with irrigation and this helps maintain nephrostomy patency.* Clots interfere with patency. The presence of small clots in the returned irrigation fluid is not a concern. - There is pain and tenderness at the surgical site but bleeding at the site is not common. - *New onset of abdominal pain with rebound tenderness may indicate a perforation, an uncommon but potentially life-threatening complication of manipulating the needles during nephrostomy placement.* - Similarly, blood loss either through the nephrostomy or surgical site can be related to a clinical important decrease in hematocrit; diuresis means that the change in hematocrit is unlikely to be from hemodilution. Inform the provider whenever this change occurs post-operatively. - *Hypertension can contribute to bleeding risk and occurrence; generally as will most post-operative or post-interventional procedures, a reasonable blood pressure goal is 120-140/80-90.*

Which statement made by a client newly diagnosed with polycystic kidney disease (PKD) in the hyperfiltration stage indicates to the nurse that additional teaching for self-management is needed? A. "I'll need to decrease my daily water intake." B. "I need to make certain my brothers and sisters know about this disease." C. "Probably the best time of day to take my lisinopril each day is with breakfast." D. "Regular low-impact exercise may help me feel better and help prevent constipation."

ANS: A - *Water restriction is contraindicated with a diagnosis of polycystic kidney disease (PKD) until the client transitions to dialysis.* A liberal water intake can reduce the harm from reduced blood flow to the kidney, including decreasing the stimulus for vasopressin release, a hormone that decreases kidney perfusion. - Once daily ACE inhibitors are first line drugs for management of hypertension in clients with PKD and developing a routine for daily administration is a good self-management approach. Complementary approaches to pain management that the client can initiate will increase in benefit from practice (rehearsal) and regular use. - *PKD is a genetic disorder.* This client's brothers and sisters also have a risk for inheriting the disorder, and early diagnosis can help ensure the correct management options are used. Thus, informing siblings is an important and ethical action in this situation. - *Constipation is a frequent problem for clients with PKD. Fluid intake and exercise can help ameliorate this problem.*

A client with diabetes has all of the following changes after a percutaneous *nephrolithotomy* procedure. Which change is most important for the nurse need to immediately report to the health care provider? A. Difficulty breathing and an oxygen saturation of 88% on 2 L of oxygen by nasal cannula B. A point-of-care blood glucose of 150 mg/dL and client report of thirst C. A decreased hematocrit by 1% (compared with preoperative values and hematuria D. An oral temperature of 38° C (101° F) and cloudiness of urine draining from the nephrostomy tube right after IV administration of a broad-spectrum antibiotic

ANS: A - All changes are somewhat abnormal but the only one that raises the level of concern to a point at which it should be immediately is the difficulty breathing and drop in oxygen saturation. *This is NOT an expected problem associated with the procedure and is potentially life-threatening.* - The blood glucose elevation, thirst, temperature elevation, cloudiness of the urine, and slight decrease in hematocrit are expected and do not pose an immediate threat.

Which question does the nurse ask the client who has a urinary tract infection to assess the risk for possible *pyelonephritis?* A. What drugs do you take for asthma? B. How long have you had diabetes? C. How much fluid do you drink daily? D. Do you take your antihypertension drugs at night or in the morning?

ANS: B - *Pyelonephritis risk is increased in the client who has diabetes and a urinary tract infection (UTI).* - While it is important to know all the drugs that a client takes, neither asthma drugs nor asthma itself increases the risk for pyelonephritis. (An exception would be high-dose systemic corticosteroids; however, these are rarely recommended in current asthma therapy). - *Although insufficient fluid intake may make a UTI worse, it does not increase the risk for pyelonephritis.* - Antihypertensives are NOT a risk factor for pyelonephritis.

A 70-year-old client is seeing his primary care provider for an annual examination. Which assessment finding alerts the nurse to an increased risk for bladder cancer? A. A five-pack year history of smoking 45 years ago B. Difficulty starting and stopping the urine stream C. A 30-year occupation as a long-distance truck driver D. A recent colon cancer diagnosis in his 72-year-old brother

ANS: C - Although cigarette smoking is a risk factor for bladder cancer, a 5-pack year history more than 45 years ago is not significant as a potential cause of cancer. - Bladder cancer does NOT appear to have a familial or genetic predisposition. - Difficulty starting or stopping urination is a symptom, usually of prostate issues, not a harbinger of bladder cancer. - *The latest research indicates exposure to gasoline and diesel fuel is a major risk factor for bladder cancer.*

When the nurse caring for a client with *severe chronic kidney disease* asks what dietary modifications he has made for the disease, he reports the following actions. Which action indicates to the nurse that additional client education is needed? A. Using a scale to measure protein weight B. Taking calcium and vitamin D supplements daily C. Eliminating bananas, citrus fruits, and avocados D. Using a salt-substitute instead of ordinary table salt

ANS: D - Salt substitutes contain very little sodium, which is a good thing because sodium restriction is needed. However, the sodium is replaced with potassium. *Clients with CKD must restrict their intake of potassium severely to avoid life-threatening cardiac dysrhythmias.*

A nurse is assessing a patient with end-stage kidney disease (ESKD) and notices that the patient's left cheek is twitching, the patient's gums are bleeding, and the patient is irritable. Which electrolyte disturbance should the nurse suspect the patient is experiencing? Hypernatremia Hyperkalemia Hypocalcemia Hypermagnesemia

Hypocalcemia - The patient is displaying signs of hypocalcemia. (normally 8.5-10.2 mg/dL) - A patient with *hypernatremia would be thirsty with sticky mucous membranes and an altered level of consciousness.* - A patient with *hyperkalemia would be anxious with nausea, vomiting, and cramps and tingling in the fingers with electrocardiogram changes.* - A patient with *hypermagnesemia would have respiratory depression, lethargy, and bradycardia.*

AKI: Postrenal causes

Obstruction

What is the most common cause of acute kidney injury (AKI) in the critically ill patient? Heart failure Shock Respiratory failure Sepsis

Sepsis - *Sepsis is the most common cause of acute kidney injury (AKI) in critically ill patients.* - Sepsis and septic shock create hemodynamic instability and *reduce perfusion to the kidney.* - Immunologic, toxic, and inflammatory factors may alter the function of the kidney microvasculature and tubular cells.

Complications of CKD flow chart *(Na balance ; K+ excretion ; Acid excretion ; Erythropoiesis)*

pic.

Which statement by a patient with chronic kidney disease (CKD) indicates an understanding of the purpose of sevelamer (Renagel) with meals? "I need this drug to prevent indigestion." "I need this drug to keep my body from absorbing too much phosphorus from food." "I need to take this drug to improve my thyroid function." "I need to take this drug with meals to avoid constipation."

"I need this drug to keep my body from absorbing too much phosphorus from food." - *Sevelamer (Renagel) is a third-generation phosphate binder.* - It is NOT ordered for indigestion or constipation, and it will NOT affect thyroid function.

The nurse educates a group of women who have had frequent urinary tract infections (UTIs) about how to avoid recurrences. Which client statement shows a correct understanding of what the nurse has taught? "I need to be drinking at least 1.5 to 2.5 liters of fluids every day." "It is a good idea for me to reduce germs by taking a tub bath daily." "Trying to get to the bathroom to urinate every 6 hours is important for me." "Urinating 1000 mL on a daily basis is a good amount for me."

"I need to be drinking at least 1.5 to 2.5 liters of fluids every day." - The client who shows a correct understanding of avoiding UTIs says, "I need to be drinking at least 1.5 to 2.5 liters of fluids every day." *To reduce the number of UTIs, clients need to be drinking a minimum of 1.5 to 2.5 liters of fluid (mostly water) each day.* - Showers, rather than tub baths, are recommended for women who have recurrent UTIs. - Urinating every *3 to 4 hours* is ideal for reducing the occurrence of UTI. This is advisable rather than waiting until the bladder is full to urinate. - *Urinary output needs to be at least 1.5 liters daily.* Ensuring this amount "out" is a good indicator that the client is drinking an adequate amount of fluid.

The nurse is teaching a client who is scheduled for a neobladder and a Kock pouch. Which client statement indicates a correct understanding of these procedures? "If I restrict my oral intake of fluids, the adjustment will be easier." "I must go to the restroom more often because my urine will be excreted through my anus." "I need to wear loose-fitting pants so the urine can flow into my ostomy bag." "I will have to drain my pouch with a catheter."

"I will have to drain my pouch with a catheter." - The client who is scheduled for a neobladder and Kock pouch correctly understands the procedure when the client says, "I will have to drain my pouch with a catheter." *A neobladder is a type of continent reservoir created from an intestinal graft to store urine and replace the surgically removed bladder.* - A *Kock Pouch* is also a continent reservoir with a Penrose drain and a plastic Medena catheter in the stoma. The drain removes lymphatic fluid or other secretions. The catheter ensures urine drainage so that incisions can heal. *For the client with a neobladder and a Kock pouch, urine is collected in a pouch and is drained with the use of a catheter.* - Urine is not excreted through the anus (lol). - Fluids would NOT be restricted. - *A neobladder does NOT require the use of an ostomy bag.*

The nurse is teaching a client with a neurogenic bladder to use intermittent self-catheterization for bladder emptying. Which client statement indicates a need for further clarification? "A small-lumen catheter will help prevent injury to my urethra." "I will use a new, sterile catheter each time I do the procedure." "My family members can be taught to help me if I need it." "Proper handwashing before I start the procedure is very important."

"I will use a new, sterile catheter each time I do the procedure." - The client with a neurogenic bladder who needs to self-catheterize for bladder emptying requires further clarification when the client says, "I will use a new, sterile catheter each time I do the procedure." *Catheters are cleaned and reused.* With proper handwashing and cleaning of the catheter, no increase in bacterial complications has been shown. *Catheters are replaced when they show signs of deteriorating.* - The smallest lumen possible and the use of a lubricant help reduce urethral trauma to this sensitive mucous tissue. - Research shows that family members in the home can be taught to perform straight catheterizations using a clean (rather than a sterile) catheter with good outcomes. - Proper handwashing is extremely important in reducing the risk for infection in clients who use intermittent self-catheterization and is a principle that must be stressed.

A 53-year-old postmenopausal woman reports "leaking urine" when she laughs and is diagnosed with stress incontinence. What does the nurse tell the client about how certain drugs may be able to help with her stress incontinence? "They can relieve your anxiety associated with incontinence." "They help your bladder to empty." "They may be used to improve urethral resistance." "They decrease your bladder's tone."

"They may be used to improve urethral resistance." - The nurse tells the 53-year-old postmenopausal woman with stress incontinence that *certain drugs may be used to improve urethral resistance.* Bladder pressure is greater than urethral resistance so drugs may be used to improve urethral resistance. - Relieving anxiety has not been shown to improve stress incontinence. - *NO drugs have been shown to promote bladder emptying, and this is not usually the problem with stress incontinence.* - Emptying the bladder is accomplished by the individual or, if that is not possible, by using a catheter. - Decreasing bladder tone would not be a desired outcome for a woman with incontinence.

The nurse is educating a female client about hygiene measures to reduce her risk for urinary tract infection (UTI). What does the nurse instruct the client to do? "Douche—but only once a month." "Use only white toilet paper." "Wipe from front to back." "Wipe with the softest toilet paper available."

"Wipe from front to back." - *Wiping front to back keeps organisms in the stool from coming close to the urethra, which increases the risk for infection.* - Douching is an unhealthy behavior because it removes beneficial organisms as well as the harmful ones. - White toilet paper helps prevent allergies, not infections. Using soft toilet paper does not prevent infection.

The nurse is teaching a client about pelvic muscle exercises. What information does the nurse include? "For the best effect, perform all of your exercises while you are seated on the toilet." "Limit your exercises to 5 minutes twice a day, or you will injure yourself." "Results should be visible to you within 72 hours." "You know that you are exercising correct muscles if you can stop urine flow in midstream."

"You know that you are exercising correct muscles if you can stop urine flow in midstream." - The nurse is telling the client about pelvic muscle exercises and says, "You know that you are exercising correct muscles if you can stop urine flow in midstream." *When the client can start and stop the urine stream, the pelvic muscles are being used.* - Pelvic muscle exercises can be performed anywhere and would be performed at least 10 times daily to improve and maintain pelvic muscle strength. *Noticeable results in pelvic muscle strength take several weeks.*

Acute Kidney Injury (AKI) *(Most commonly caused by?)* *(Pre/Intra/Post)* *(Results in ; Kidney compensation)* *(What lab value increase do we look for to indicate AKI?)*

- *An Increase in serum creatinine by 0.3 mg/dL or more within 48 hours or an increase x1.5 from baseline within a week.* Also, significant depletion in urine output! Always check. - Acute kidney injury (AKI) is a *rapid reduction in kidney function* resulting in a failure to maintain waste ELIMINATION, FLUID AND ELECTROLYTE BALANCE, and ACID-BASE BALANCE. *AKI occurs over a few hours or days.* - *The causes of AKI are reduced PERFUSION to the kidneys (PRE), damage to kidney tissue (INTRA), and obstruction of urine outflow (POST).* - *Although glomerular filtration rate (GFR) is accepted as the best overall indicator of kidney function, it is NOT accurate during acute and critical illness.* Instead, we are looking for *Creatinine levels.* - *With PRErenal or POSTrenal pathology, the kidney compensates by the three responses of constricting kidney blood vessels, activating the renin-angiotensin-aldosterone pathway, and releasing antidiuretic hormone (ADH).* These responses *increase* blood volume and improve kidney PERFUSION. However, these same responses reduce urine ELIMINATION, resulting in *oliguria (urine output less than 400 mL/day)* and *azotemia (the retention and buildup of nitrogenous wastes in the blood).* Toxins can also cause blood vessel constriction in the kidney, leading to reduced kidney blood flow, oliguria, and azotemia. - *Keep in mind that dehydration (severe blood volume depletion) reduces PERFUSION and can lead to AKI even in adults who have no known kidney problems. Urge all healthy adults to avoid dehydration by drinking 2 to 3 L of water daily.* - *Timely interventions to remove the cause of AKI may prevent progression to ESKD and the need for lifelong renal replacement therapy or a renal transplant.* - Monitor laboratory values for any changes that reflect poor kidney function. *A significant increase in CREATININE, especially when the increase occurs over hours or a few days, is a concern and must be reported urgently to the primary health care provider.*

Hemodialysis: Preprocedure

- *Assess the patency of a long-term device: Arteriovenous (AV) fistula or AV graft* (presence of bruit, distal pulses) - Avoid measuring BP, administering injections, performing venipunctures, or insertive IV catheters on or into the arm with an access site. - Elevate the extremity following surgical creation of an AV fistula to reduce swelling - Assess Vital signs, lab values (BUN, creatinine, electrolytes, hct) and weight. - *Inform the client that they will need hemodialysis three times per week, for 3-5 hour sessions. The provider will insert two needles, one into the artery and the other into the vein.*

UTIs (Common symptoms, Rare symptoms)

- *Frequency, urgency, and dysuria are the common symptoms of a urinary tract infection (UTI),* but other symptoms may be present (pic). - Urine may be cloudy, foul smelling, or blood tinged. Ask the patient about risk factors for UTI during the assessment. - *The prostate is palpated by digital rectal examination (DRE) by the primary health care provider* for size, change in shape or consistency, and tenderness. *A large prostate gland can obstruct urine outflow and contribute to urostasis and bacterial colonization of the urinary tract, contributing to the risk for a complicated UTI.*

Incontinence (4 types)

- *Incontinence is an involuntary loss of urine* severe enough to cause social or hygienic problems. - The most common types of adult urinary incontinence are *stress incontinence, urge incontinence, overflow incontinence, and functional incontinence.*

Interstitial cystitis

- *Interstitial cystitis is a rare, chronic inflammation of the ENTIRE lower urinary tract (bladder, urethra, and adjacent pelvic muscles) that is related to genetic and IMMUNITY dysfunction rather than infection.* - The condition affects women six to seven times more often than men, and the diagnosis is difficult to make. - *Symptoms are pain associated with bladder filling or voiding, usually accompanied by frequency, urgency, and nocturia.* Pain occurs in suprapubic or pelvic areas, sometimes radiating to the groin, vulva, or rectum.

Hemodialysis (Indications for use, what it does)

- *Kidney replacement therapy (KRT) is needed when the pathologic changes of stage 4 and stage 5 CKD are life threatening or pose continuing discomfort.* - Intermittent hemodialysis (HD) is the most common KRT used with ESKD. *Dialysis removes excess fluids and waste products and restores FLUID AND ELECTROLYTE BALANCE and ACID-BASE BALANCE.* Hemodialysis requires vascular access. - HD involves passing the patient's blood through an *artificial semipermeable membrane* to perform the kidney's filtering and excretion functions.

Pyelonephritis *(What it is ; What typically causes it)* *(Acute symptoms)*

- *Pyelonephritis is a bacterial infection in the kidney and renal pelvis* - *Acute pyelonephritis is an active bacterial infection.* Bacterial infection causes local (e.g., kidney) and systemic (e.g., fever, aches, and malaise) inflammatory symptoms. - In pyelonephritis, organisms usually move UP from the urinary tract into the kidney tissue. This is more likely to occur when urine refluxes *from the bladder into the ureters and then to the kidney. Reflux* is the reverse or upward flow of urine toward the renal pelvis and kidney.

Hemodialysis: Intraprocedure Nursing actions

- Always monitor for complications during dialysis such as *clotting, air bubbles in blood tubing, and temperature of dialysate (100°F). - Hypotension, cramping, vomiting, and bleeding at the access site may occur and should be addressed promptly. - *Administer anticoagulants*. Heparin prevents clotting of the blood. *Monitor aPTT to assess for risk of hemorrhage.* Have protamine sulfate available ready to reverse heparin overdose. - Advise client to notify the nurse of headache, nausea, or dizziness during dialysis; and advise client not to eat during procedure. - To access a fistula, cannulate it by inserting two needles: *one toward the venous blood flow and one toward the arterial blood flow.* This procedure allows the HD machine to draw the blood out through the arterial needle and return it through the venous needle. *Arteriovenous grafts* are used when the AV fistula does not develop or when complications limit its use.

Renal Cell Carcinoma *(Paraneoplastic syndrome s/s)* *(Anemia or Erythrocytosis cause and lab value to look for)* *(Management, Microwave ablation)*

- *Renal cell carcinoma (RCC) or adenocarcinoma* of the kidney is the most common type of *kidney cancer* - *Systemic effects* occurring with this cancer type are called *PARANEOPLASTIC SYNDROMES and include anemia, erythrocytosis, hypercalcemia, liver dysfunction with elevated liver enzymes, hormonal effects, increased sedimentation rate, and hypertension.* - The most common treatment for RCC is a *nephrectomy (kidney removal).* Renal cell tumors are highly vascular, and blood loss during surgery is a major concern. - When the cancer is local (i.e., only in the kidney), a nephrectomy can provide a cure. *For patients with metastasis, nephrectomy is followed by targeted chemotherapy* combined with cytokine treatment. - Some patients with RCC have flank pain, obvious blood in the urine, and a kidney mass that can be palpated. *Bloody urine is a LATE common sign.* - *Microwave ablation (MWA) or cryoablation can slow tumor growth.* It is a minimally invasive procedure carried out after MRI has precisely located the tumor. *MWA is used most commonly for patients who have only one kidney or who are not surgical candidates.* - A decrease in blood pressure post-op is an early sign of both *hemorrhage and adrenal insufficiency.* With hypotension, urine output also decreases immediately. Large water and sodium losses in the urine occur in patients with adrenal insufficiency, leading to impaired FLUID AND ELECTROLYTE BALANCE. As a result, a large urine output is followed by hypotension and oliguria *(less than 400 mL/24 hr or less than 25 mL/hr).* IV replacement of fluids and packed RBCs may be needed.

Chronic Kidney Disease: Management *(Dietary restrictions- if patient has little urine output ; Muscle Strength ; Preventing excess fluid overload)*

- *Sodium restriction is needed in patients with little or no urine output* to maintain FLUID AND ELECTROLYTE BALANCE. *Both fluid and sodium retention cause edema, hypertension, and heart failure (HF).* Most patients with CKD retain sodium; a few cannot conserve sodium. - Monitor the ECG for *tall, peaked T waves caused by hyperkalemia* or *flat T waves caused by hypokalemia.*

Incontinence (Interventions to help with each one)

- *Stress incontinence is the most common type.* Its main feature is the inability to retain urine when *laughing, coughing, sneezing, jogging, or lifting.* - *Urge incontinence is the loss of urine for no apparent reason after suddenly feeling the need or urge to urinate.* Normally when the bladder is full, contraction of the smooth muscle fibers of the bladder detrusor muscle signals the brain that it is time to urinate. - *Overflow incontinence occurs when the detrusor muscle fails to contract and the bladder becomes overdistended.* The bladder has reached its maximum capacity and some urine must *leak out* to prevent bladder rupture

Bacteriuria

- *The presence of bacteria in the urine is bacteriuria* and may occur with cystitis or any UTI. - When the patient has bacteriuria but NO symptoms of infection, it is called colonization, or *asymptomatic bacterial urinary tract infection or ABUTI,* and is more common in older adults. This problem may progress to acute infection or renal insufficiency when the patient has other conditions, and only then does it require treatment. - *The urinary and genitourinary tracts are normally STERILE, apart from the distal urethra.*

Urethritis (Cause by, s/s)

- *Urethritis is an inflammation of the urethra* and can result from infectious and noninfectious conditions. - *Symptoms of urethritis include discharge of mucopurulent or purulent material, dysuria, and itching or discomfort of the area (urethral pruritus).* The discharge can be any color, depending on the infecting organism or source of irritation. *Additional symptoms may include fever (with or without chills) and urgent or frequent urination.*

Urolithiasis (Kidney Stones) *(pain relief, Lithotripsy, causes, renal colic/ flank pain, UTO)*

- *Urolithiasis is the presence of calculi (stones) in the urinary tract.* Stones often do not cause symptoms until they pass into the *lower urinary tract,* where they can cause excruciating pain. - The most common condition associated with stone formation is *dehydration.* - Surgical Management includes *retrograde ureteroscopy* in which you go in with forceps to remove the calculi. - Any stone may result in *obstruction* within the urinary tract, which can threaten both *glomerular filtration rate (GFR) and kidney perfusion.* - *Hematuria (bloody urine) may result from damage to the urothelial lining.* If the obstruction is not removed, *urinary stasis can lead to infection* and impair kidney function on the side of the blockage. As the blockage persists, *hydronephrosis* (enlargement of the kidney caused by blockage of urine lower in the tract and filling of the kidney with urine) and permanent kidney damage may develop. - The major symptom of stones is severe pain, commonly called *renal colic.* - *Flank pain suggests that the stone is in the kidney or upper ureter.* Flank pain that extends toward the abdomen or to the scrotum and testes or the vulva suggests that stones are in the ureters or bladder. - Renal colic begins suddenly and is often described as "unbearable." *Nausea, vomiting, pallor, and diaphoresis often accompany the pain.* - *Urinary tract obstruction is an emergency and must be treated immediately to preserve kidney function!!* Assess the patient for bladder distention.

Acute Glomerulonephritis (Patient assessment- Connection with?, Clinical manifestations, Lab assessment, Management)

- Acute glomerulonephritis (GN) develops suddenly from an *excess IMMUNITY response* within the kidney tissues. - *Usually an infection is noticed before kidney symptoms of acute GN are present.* - The onset of symptoms is about 10 days from the time of infection. Usually patients recover quickly and completely from acute GN. - *Assess for fluid overload and pulmonary edema that may result from fluid and sodium retention occurring with acute GN.* - *Urinalysis shows red blood cells (hematuria) and protein (proteinuria).* - Penicillin, erythromycin, or azithromycin is prescribed for GN caused by *streptococcal infection.* - Potassium and protein intake may be restricted to prevent hyperkalemia and uremia as a result of the elevated BUN. Antihypertensive drugs may be needed to control hypertension - *Nausea, vomiting, or anorexia indicates that uremia is present.*

UTIs (Acute vs Recurrent) (factors contributing to UTIs)

- An infection can occur in any area of the *urinary tract and the kidney.* Such infections are known as urinary tract infections or *UTIs.* - An *acute UTI* is the invasion of a normal urinary tract by an infectious organism. *A recurrent UTI occurs as more than two infections in 6 months or more than three infections in 1 year.* These distinctions in UTIs are important because they have different approaches to management. - About 10% of young, sexually active women experience a UTI each year, and *60% of all women have one or more UTIs in their lifetime.* Most UTIs are acute and uncomplicated in women. Acute, uncomplicated UTIs rarely occur in men.

Diabetic Nephropathy *(First sign: Persistent ____)* *(leading cause of ____)*

- Diabetic nephropathy is a vascular complication of chronic loss of kidney function from diabetes mellitus (DM) and is the leading cause of *end-stage kidney disease (ESKD)* - Severity of diabetic kidney disease is related to the degree of hyperglycemia the patient generally experiences. *With poor control of hyperglycemia,* the complicating problems of atherosclerosis, hypertension, and neuropathy (which promotes loss of bladder tone, urinary stasis, and urinary tract infection) are more severe and more likely to cause kidney damage.

Hemodialysis: Procedure

- Dialysis works using the passive transfer of toxins by DIFFUSION. *Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration.* - When HD is started, *blood and dialysate (dialyzing solution)* flow in *opposite* directions across an enclosed *semipermeable membrane.* - The *dialysate* contains a balanced mix of electrolytes and water that closely resembles human plasma. - *On the other side of the membrane is the patient's blood,* which contains nitrogen waste products, excess water, and excess electrolytes - *During HD, the waste products move from the blood INTO the dialysate because of the difference in their concentrations (diffusion).* Some water is also removed from the blood into the dialysate by *osmosis.* - This circulating process continues for a preset length of time, removing nitrogenous wastes, reestablishing FLUID AND ELECTROLYTE BALANCE, and restoring ACID-BASE BALANCE. - The HD system includes a *dialyzer, dialysate, vascular access routes, and an HD machine.* - The *artificial kidney, or dialyzer* has four parts: a blood compartment, a dialysate compartment, a semipermeable membrane, and an enclosed support structure.

Hydronephrosis and Hydroureter

- Hydronephrosis and hydroureter are problems of urinary ELIMINATION with *outflow obstruction.* - *Urethral strictures obstruct urine outflow and may contribute to bladder distention, hydroureter, and hydronephrosis.* - *In HYDRONEPHROSIS, the kidney enlarges as urine collects in the renal pelvis and kidney tissue.* - *In patients with HYDROURETER (enlargement of the ureter), the effects are similar, but the obstruction is in the ureter rather than in the kidney.* Ureter dilation occurs above the obstruction and enlarges as urine collects. - Causes of hydronephrosis or hydroureter include *tumors, stones, trauma, structural defects, and fibrosis.* - *Urinary retention and potential for infection are the primary problems.* Failure to treat the cause of obstruction leads to infection and acute kidney injury (AKI).

Laboratory Assessment for identifying UTI

- Laboratory assessment for a UTI begins with a *clean-catch urine specimen* that is divided into two containers. For a routine urinalysis, 10 mL of urine is needed; smaller quantities are sufficient for culture. - Urine culture is expensive, and initial results take at least 24 hours. *Antibiotic therapy is used for bacterial UTIs*

S/S of Chronic Kidney Disease *(Neurologic, Cardiovascular , Respiratory, Hematologic, Gastrointestinal, Skeletal, Urinary, Skin)*

- Management of the patient with CKD includes *drug therapy, nutrition therapy, fluid restriction, and dialysis (when the patient reaches Stage 5).* - Hemodialysis is performed intermittently for 3 to 4 hours, typically 3 days per week. - Weight gain may indicate fluid retention from poor kidney function with disrupted FLUID AND ELECTROLYTE BALANCE. Weight loss may be the result of anorexia from *uremia.* *(1 L of water weighs 1 kg)*

Hemodialysis: Postprocedure Nursing actions (lab values, weight, bleeding risk, folate diet, Dialysis Disequilibrium Syndrome)

- Monitor vital signs and lab values (BUN, serum creatinine, electrolytes, hct). A decrease in BP and lab values is common following dialysis. - Compare the clients weight pre and post procedure to estimate amount of fluid removed. *1 L fluid equals 1 kg or 2.2 lbs*. - Avoid invasive procedures for *4-6 hours* after dialysis due to risk of bleeding as a result of anticoagulation. - Eat foods high in *folate* (beans, green vegetables) - *Disequilibrium syndrome results from too rapid a decrease of BUN and circulating fluid volume.* It can result in *cerebral edema and increased ICP.* Manifestations include n/v, changes in LOC, seizures and agitation. - If client has DS, *slow dialysis exchange rate, and administer anticonvulsants or barbiturates if the client requires them.*

Nephrotic Syndrome (main feature, s/s, treatment)

- Nephrotic syndrome (NS) is an *immunologic* kidney disorder in which *glomerular permeability increases so larger molecules pass through the membrane into the urine and are then excreted.* - *This process causes massive loss of protein into the urine, edema formation, and decreased plasma albumin levels.* (All *glomerulonephritis* diseases have features of nephrosis) - The most common cause of glomerular membrane changes is altered IMMUNITY with inflammation. It may also be genetic. - *Altered liver function* may occur with NS, resulting in increased lipid production and *hyperlipidemia.*

Urolithiasis Interventions

- Nursing interventions focus on promoting COMFORT and *preventing infection and urinary obstruction.* - The larger the stone and the higher up in the urinary tract it is, the less likely it is to pass. When the stone is passed, it should be captured and sent to the laboratory for analysis. - *Drug therapy is needed in the first 24 to 36 hours when pain is most severe. Opioid analgesics* are used to control the severe pain caused by stones in the urinary tract and may be given IV for rapid pain relief. *NSAIDs such as ketorolac (Toradol) or ketoprofen (Nexcede) in the acute phase may be quite effective.* (When NSAIDs are used, there is an increased risk for kidney impairment from reduced perfusion.) - *Lithotripsy* or extracorporeal shock wave lithotripsy (SWL) is the use of sound, laser, or dry shock waves to break the stone into small fragments. *ECG MONITORING!* - Drugs to treat hypercalciuria (high levels of calcium in the urine) include *thiazide diuretics.*

Peritoneal Dialysis: Complications (Peritonitis; Protein loss ; Hyperglycemia ; Constipation)

- PD can allow micro-organisms into the peritoneum and cause *peritonitis.* Maintain surgical asepsis during the procedure, and monitor for infection such as fever, purulent drainage, redness and swelling. - Monitor *serum albumin levels* as PD can remove protein from the blood as well as excess fluid, wastes, and electrolytes. Client may have to increase dietary protein. - *Hyperglycemia* can result from the hyperosmolarity of the dialysate. The blood may absorb glucose from the dialysate. *Monitor serum glucose levels and administer insulin for glycemic control.* - Obstruction or twisting of the tubing can decrease the flow and cause *constipation.*

Peritoneal Dialysis *(Advantage/Disadvantage ; How it works ; Indications)*

- Peritoneal dialysis (PD) allows exchanges of wastes, fluid, and electrolytes to occur in the peritoneal cavity. *However, PD is slower than hemodialysis (HD), and more time is needed to achieve the same effect.* Other disadvantages of PD are the protein loss in outflow fluid, risk for peritoneal injury, and potential discomfort from indwelling fluid. - PD involves instillation of *hypertonic dialysate solution* into the peritoneal cavity. The peritoneum serves as the filtration membrane. - PD is the treatment of choice in older adults who require dialysis as well as those *unable to tolerate anticoagulants, have difficulty with vascular access, have chronic disease such as DM, HF, or severe hypertension.*

Polycystic Kidney Disease (PKD) (Symptoms; type of disorder; Most patients with PKD have ___)

- Polycystic kidney disease (PKD) is a *GENETIC* disorder in which *fluid-filled cysts develop in the nephrons.* - Relentless development and growth of cysts from loss of CELLULAR REGULATION and abnormal cell division result in *progressive kidney enlargement.* - PKD is associated with *hypertension,* abdominal fullness and pain, episodes of cyst bleeding, *hematuria, kidney stone formation*, infections, and systemic disease. - The cysts look like clusters of grapes. Over time, growing cysts damage the glomerular and tubular membranes. Each cystic kidney enlarges, becoming the size of a football, and may weigh 10 lb or more each. *As cysts fill with fluid and become larger, kidney function becomes less effective, and urine formation and waste ELIMINATION are impaired.*

The *urinary tract* includes: (their role, problems that arise from dysfunction?)

- The urinary tract includes the *ureters, bladder, and urethra.* - Although these structures play NO role in the making of urine, their functions are essential for the urine made by the kidneys to be *eliminated from the body.* - Both infectious and noninfectious problems in the urinary tract can disrupt urinary ELIMINATION and *affect control of fluids, electrolytes, nitrogenous wastes, and blood pressure.* - *Nursing interventions are directed toward prevention, detection, and management of urologic disorders.*

AKI: Prerenal causes *(s/s of decreased perfusion)* *(MAP < __)*

- Traditionally, AKI caused by *REDUCED PERFUSION* with a sustained *mean arterial pressure (MAP) of less than 65 mm Hg* is classed as prerenal failure. - Assess continually to recognize the signs and symptoms of volume depletion *(low urine output, decreased systolic blood pressure, decreased pulse pressure, orthostatic hypotension, thirst, rising blood osmolarity)*. - Respond by intervening early with oral fluids or, in the patient who is unable to take or tolerate oral fluid, *requesting* an increase in IV fluid rate from the primary health care provider to prevent permanent kidney damage. - If a patient has a *urinary catheter,* assess urine output *every hour* after surgery until stable, during fluid resuscitation for shock or hypotension, and when the patient has a high risk for AKI following hospital admission. *Even a brief period of oliguria, defined as less than 0.5 mL/kg/hour of urine output for 2 or more hours, can signal AKI.*

Chronic Kidney Disease *(azotemia, uremia, stages)*

- Unlike acute kidney injury (AKI), *chronic kidney disease (CKD) is a progressive, IRREVERSIBLE disorder, and kidney function does NOT recover.* - It is defined as abnormalities in kidney structure or function that alter health and are present for *longer than 3 months.* - When kidney function and waste ELIMINATION are too poor to sustain life, CKD becomes *end-stage kidney disease (ESKD).* - Terms used with CKD include *azotemia (buildup of nitrogen-based wastes in the blood), uremia (azotemia with symptoms), and uremic syndrome.* - *CKD is classified into FIVE stages based on glomerular filtration rate (GFR) category*

Urothelial Cancer (what is it? how is it diagnosed? How is it treated? Surgical interventions? First indication that you may have it?)

- Urothelial cancers are *malignant* tumors of the urothelium, which is the lining of transitional cells in the kidney, renal pelvis, ureters, urinary bladder, and urethra. *Most urothelial cancers occur in the bladder, and the term "bladder cancer" describes this condition.* - Once the cancer spreads beyond the transitional cell layer, it is *highly invasive and can spread beyond the bladder.* Because of the nature of this cancer, patients may have recurrence up to 10 years after being cancer free. - *Chemotherapy and radiation therapy are used in addition to surgery.* If untreated, the tumor invades surrounding tissues, spreads to distant sites (liver, lung, and bone), and ultimately leads to death.

AKI vs CKD

- When kidney function declines *gradually*, it is diagnosed as *CKD.* The patient may have many years of abnormal blood urea nitrogen and creatinine values before ESKD develops. - When kidney function decline is *sudden, acute kidney injury (AKI) is diagnosed.* AKI can be a temporary condition that resolves, or it can progress to CKD. Even without progression to CKD, AKI is associated with high mortality in critically ill adult. - Acute kidney injury affects MANY body systems. Chronic kidney disease affects EVERY body system. - The problems that occur with kidney function loss are related to disturbances of FLUID AND ELECTROLYTE BALANCE, disturbances of ACID-BASE BALANCE, buildup of nitrogen-based wastes (uremia), and loss of kidney hormone function. - Both types of kidney problems can require kidney replacement therapy *(e.g., dialysis).*

Cutaneous ureterostomy

- With *cutaneous ureterostomy* or ureteroureterostomy, *the ureter opening is brought out onto the skin.* The cutaneous ureterostomies may be located on either side of the abdomen or side by side. *After cutaneous ureterostomy, an external pouch covers the ostomy to collect urine and maintain TISSUE INTEGRITY.* - After cutaneous ureterostomy, an external pouch covers the ostomy to collect urine and maintain TISSUE INTEGRITY. - The patient with a Kock's pouch, a continent reservoir, may have a Penrose drain and a plastic Medena catheter in the stoma. The drain removes lymphatic fluid or other secretions; the catheter ensures urine drainage so incisions can heal. *The patient with a neobladder usually requires 2 to 4 days in the ICU and will have a drain at first in the event the neobladder requires irrigation.* - Infection is common in patients who have a neobladder. Teach patients and family members the symptoms of infection and the importance of reporting them immediately to the surgeon.

What is the fluid resuscitation choice for the patient with a traumatic brain injury (TBI)? 4% albumin 0.9% normal saline 0.45% NaCl Mannitol

0.9% normal saline - The SAFE results showed that there was NO difference in the mortality rate, time in the critical care unit, ventilator days, or renal replacement therapy days between administration of 0.9% normal saline and 4% albumin for fluid resuscitation. *The researchers concluded that albumin and saline should be considered clinically equivalent treatments for intravascular volume expansion in critically ill patients. The exception was for patients with traumatic brain injury (TBI), in which case albumin was associated with a higher mortality rate.* - *Mannitol is reserved for osmotic diuresis, NOT fluid resuscitation.*

What information will the nurse provide to a client who is scheduled for extracorporeal shock wave lithotripsy? *Select all that apply.* "Your urine will be strained after the procedure." "Be sure to finish all of your antibiotics." "Immediately call the primary health care provider if you notice bruising." "Remember to drink at least 3 liters of fluid a day to promote urine flow." "You will need to change the incisional dressing once a day."

1,2,4 - The nurse tells the client scheduled for an extracorporeal shock wave, "Your urine will be strained after the procedure," "Be sure to finish all of your antibiotics," and "Remember to drink at least 3 liters of fluid a day to promote urine flow." - *After lithotripsy, urine is strained to monitor the passage of stone fragments.* Clients must finish the entire antibiotic prescription to decrease the risk of developing a urinary tract infection. *Drinking at least 3 L of fluid a day dilutes potential stone-forming crystals, prevents dehydration, and promotes urine flow.* - Bruising on the flank of the affected side is *expected* after lithotripsy as a result of the shock waves that break the stone into small fragments. *The client must notify the primary health care provider if he or she develops pain, fever, chills, or difficulty with urination because these signs and symptoms may signal the beginning of an infection or the formation of another stone.* - There is no incision with extracorporeal shock wave lithotripsy. There may be a small incision when intracorporeal lithotripsy is performed.

A patient is having an abdominal computed tomography (CT) scan with intravenous (IV) contrast in the morning. Which instructions should be included in the teaching for this procedure? *Select all that apply.* The patient should report any allergies to shellfish. The patient should drink several glasses of water after the procedure. The patient should drink 3 glasses of water before the procedure. The patient should be NPO (nothing by mouth) and have IV fluids discontinued before the test. The patient will have an IV started if one is not already in place before the procedure.

1,2,5 - Shellfish allergies are associated with iodine and contrast dye. - It is important for the patient to be well hydrated *before and after* the administration of contrast. The patient will need an IV for IV contrast. If oral contrast is ordered, the patient will be required to drink most or all of it (because the lowest dose necessary should be ordered); IV contrast does not require this. - *The patient should be hydrated, so even if the patient takes nothing by mouth, fluids should not be discontinued.*

Which interventions are helpful in preventing Urothelial (bladder) cancer? *Select all that apply.* Drinking 2½ liters of fluid a day Showering after working with or around chemicals Stopping the use of tobacco Using pelvic floor muscle exercises Wearing a lead apron when working with chemicals Wearing gloves and a mask when working around chemicals and fumes

2,3,6 - The interventions that are helpful in preventing bladder cancer are: *showering after working with or around chemicals, stopping the use of tobacco, and wearing gloves and a mask when working around chemical and fumes.* - Certain chemicals (e.g., those used by professional hairdressers) are known to be carcinogenic in evaluating the risk for bladder cancer. Protective gear is advised. *Bathing after exposure to them is advisable.* - Tobacco use is one of the highest, if not the highest, risk factor in the development of bladder cancer. - *Increasing fluid intake is helpful for some urinary problems such as urinary tract infection, but no correlation has been noted between fluid intake and bladder cancer risk.* - Using pelvic floor muscle strengthening (Kegel) exercises is helpful with certain types of incontinence, but no data show that these exercises prevent bladder cancer. - Precautions must be taken when working with chemicals. *However, lead aprons are used to protect from radiation.*

The nurse receives the change-of-shift report on four clients. Which client does the nurse decide to assess first? A 26-year-old admitted 2 days ago with urosepsis with an oral temperature of 99.4°F (37.4°C) A 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours A 32-year-old admitted with hematuria and possible bladder cancer who is scheduled for cystoscopy A 40-year-old with noninfectious urethritis who is reporting "burning" and has estrogen cream prescribed

A 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours - After change-of-shift report, the nurse decides to first assess a 28-year-old with urolithiasis who has been receiving morphine sulfate and has not voided for 8 hours. *Anuria may indicate urinary obstruction at the bladder neck or urethra and is an emergency because obstruction can cause acute kidney failure.* The client who has been receiving morphine sulfate may be over sedated and may not be aware of any discomfort caused by bladder distention. - The 26-year-old admitted with urosepsis and slight fever, the 32-year-old scheduled for cystoscopy, and the 40-year-old with noninfectious urethritis are not at immediate risk for complications or deterioration.

A 48-year-old African-American man is newly diagnosed with hypertension and Stage 1 chronic kidney disease (CKD). His primary health care provider has prescribed a thiazide diuretic. The client reports that he has increased his activity and changed his diet, which resulted in a 10-lb (4.5-kg) weight loss in the past 2 months. The client says he feels well and does not want to take any drugs. What is the nurse's best response? A. "Reducing your blood pressure may slow or prevent progression of your chronic kidney disease." B. "Your primary health care provider prescribed the diuretic because it will reverse the damage caused by kidney disease." C. "Taking medications is a personal decision, and you have the right to decline this prescription." D. "Because your lifestyle changes have resulted in weight loss, this intervention is all that is needed to reduce your risk for progression of kidney disease."

ANS: A - *African Americans have greater risk for hypertension, CKD, and complications from both conditions.* Blood pressure control is critical in the treatment of patients with CKD - lowering the blood pressure reduces the risk of stroke, MI, and progression of CKD. - *Stage 1 CKD already indicates some irreversible damage. Management of blood pressure at this stage of CKD can greatly slow its progression.* - A diuretic does NOT improve kidney function or reverse CKD damage. It does not alter the course of CKD progression. *It does improve elimination of fluid, and fluid overload can contribute to hypertension.* - While personal values and preferences are essential decision points in determining a plan of care for each adult, it is also important that the client be well informed about the consequences of decisions. His risk for progression of CKD is not low and his blood pressure has not achieved a target goal, despite weight loss. It is time to consider additional interventions such as drug prescription. - While this client has had a good outcome from diet and lifestyle, it has not been sufficient to meet targeted blood pressure goals and cannot slow progression of CKD.

Which actions/interventions are most important for the nurse to perform when caring for a 70-year-old client who is scheduled for a contrast-medium enhanced CT scan? *Select all that apply.* A. Assess for coexisting conditions of pre-existing diabetes, heart failure, and established CKD. B. Assess the hourly urine output for at least 6 hours before the procedure. C. Assess creatinine clearance using a 24-hour urine collection test. D. Alert the primary health care provider to a serum creatinine that has increased from 0.2 to 0.4 mg/dL (20-40 mcmol/L) in the previous 24 hours. E. Alert the primary health care provider to a glomerular filtration rate (GFR) <60 mL/min/1.73 m2. F. Assess for hypovolemia, including evaluation of the mean arterial pressure (MAP). G. Collaborate with the primary health care provider to determine whether isotonic IV fluids should be infused before the test. H. Discuss with the primary health care provider about whether the client's prescribed diuretic should be held immediately before the test.

ANS: A, E, F, G, H - *Identification of risk factors and correction of modifiable factors is essential to prevent CONTRAST-INDUCED NEPHROPATHY.* Risk factors have a cumulative property, so reduction of the number of modifiable risk factors is key to good patient outcomes. - Pre-existing conditions that are associated with impaired kidney function including diabetes, heart failure, and advanced age are red flags that alert the nurse to increased risk for kidney damage from toxins like contrast media. - Established CKD (diagnosed via serum creatinine and GFR) also indicates that an individual may not tolerate contrast without subsequent harm. - Not all clients will have a urinary catheter nor is one necessary. *Do evaluate the urine characteristics, but hourly measurements of volume are not necessary.* - Creatinine clearance can be estimated with a single serum creatinine level; a 24-hour urine test is NOT an appropriate laboratory test for this situation. - Although there is an increase in serum creatinine, the values are normal and the increase does not meet any criteria for AKI (i.e., increases of 0.3 to 0.5 mg/dL [26.2 to 50 mcmol/L]). This small increase may be the result of recent protein intake (diet) or exercise. *More information is needed before contacting the provider.* - A GFR <60mL/kg/1.73 m2 is the threshold for impaired kidney function and diagnostic of significant CKD. Other conditions that increase the potential for harm from contrast include sepsis, shock, and even hypocholesteremia. Infection and vascular conditions can also increase risk for contrast-induced nephropathy. *Dehydration or blood volume contraction increases risk for AKI from hypoperfusion.* - Adding contrast increases the number of risk factors. *MAP is a marker of adequate hydration and used to reduce risk from hemodynamic instability or hypotension.* - IV fluid administration is one strategy to ensure adequate intravascular volume to reduce kidney hypoperfusion and to increase elimination of the contrast so that the agent has less time to damage tubular epithelium. IV fluids also dilute the contrast, reducing exposure and harm. - Holding diuretic(s) prior to contrast administration reduces the possibility of hypovolemia and hypotension around the time of contrast administration. Diuretics may be given subsequent to IV fluid administration (to dilute and eliminate contrast) to maintain euvolemia but *diuretics are not typically given BEFORE contrast.*

The client is a 62-year-old admitted 2 days ago with traumatic injuries and hypovolemic shock from a car crash. The nurse reviewing the client's daily laboratory test results notices the following values. Which result is most important to report to the primary health care provider immediately? A. Serum sodium 132 mEq/L (mmol/L) B. Serum potassium 6.9 mEq/L (mmol/L) C. Blood urea nitrogen 24 mg/dL (mmol/L) D. Hematocrit 32% (0.32 volume fraction); hemoglobin 9.2 g/dL (92 g/L) *(Normal hct, hgb, and BUN levels?)*

ANS: B - All listed laboratory values are out of the normal range. However, the only value that has reached or is approaching a critical level is the serum potassium, which shows *hyperkalemia.* This problem must be addressed immediately. *- Hct: 40-50% (RBCs in the blood)* *- Hgb: 12-16 g/dL* *- BUN: 5-20*

When assessing a client with acute glomerulonephritis, which question about self-management will the nurse ask to determine whether the client is currently following best practices to slow progression of kidney damage? A. "Have you increased your protein intake to promote healing of the damaged nephrons?" B. "Do you avoid contact sports while you're taking cyclosporine?" C. "How are you evaluating the amount of daily fluid you drink?" D. "Have you contacted anyone from our dialysis support services?"

ANS: C - Because the client needs to find a balance between too much and too little fluid intake (both are harmful), this is a good question to see how the individual ensures adequate kidney blood flow *(perhaps with systemic blood pressure assessment)* while providing sufficient intake to eliminate waste (perhaps through urine volume or color or via staying within a target of fluid intake. *A target fluid intake is generally 1.5 to 2 L daily if not receiving dialysis).* - *Cyclosporine is a cytotoxic agent that reduces immune responses, which would require the client to avoid sick people, not contact sports.* - The client may not progress to needing dialysis; this intervention is usually reserved until the last stage of CKD before dialysis occurs; there is no indication that CKD has been staged at this point.

A client who performs home continuous ambulatory peritoneal dialysis reports that the drainage (effluent) has become cloudy in the past 24 hours. What is the nurse's best first action? a. Remove the peritoneal catheter. b. Notify the health care provider immediately. c. Obtain a sample of effluent for culture and sensitivity. d. Explain to the client the need to keep the dialysate in the refrigerator to prevent bacterial overgrowth.

ANS: C - The client most likely has beginning *peritonitis.* This problem needs to be confirmed and interventions started quickly. *A culture is needed to identify that an infection is indeed present.* - Although the health care provider does need to be notified, obtaining the culture is performed first. - The peritoneal catheter should not be removed at this time because it may be needed to instill intraperitoneal antibiotics. - Also, removal of this catheter in not within the scope of practice for registered nurses in most states. Dialysate for peritoneal dialysis is sterile and does not need to be refrigerated.

The nurse is preparing a client for discharge who developed an acute kidney injury during coronary artery bypass graft surgery. The nurse notices that the client has a serum creatinine of 1.2 mg/dL (106 mcmol/L) and a glomerular filtration rate (GFR) of 75 mL/kg/1.73 m2. Which is the priority nursing action? A. Reminding the client to remain hydrated by drinking 500 mL of an electrolyte-based solution daily B. Encouraging the client to reduce protein intake to reduce creatinine production until the follow-up visit with the nephrologist occurs C. Checking the remaining values on the metabolic panel and informing the primary care provider of all results before the client is discharged D. Educating the client about the need for follow-up, including re-evaluation of serum creatinine with the primary care provider or nephrologist in 8-12 weeks

ANS: D - The serum creatinine is within normal limits but the *GFR is reduced, indicating risk for CKD.* Follow-up is needed but not urgently and follow-up should occur within the health care team members who are familiar with her hospital course and general health. - *Protein is an essential nutrient needed for wound healing after surgery. A normal creatinine typically does not require protein restriction to avoid progression of kidney problems.* - Water or electrolyte-free fluid is recommended for hydration unless there is an indication that electrolytes are being excreted in urine. - Although the rest of the metabolic panel should be evaluated by the discharge nurse, *the primary care provider need only be informed of critical values in an urgent manner.*

A client who is admitted with urolithiasis reports "spasms of intense flank pain, nausea, and severe dizziness." Which intervention does the nurse implement first? Administer morphine sulfate 4 mg IV. Begin an infusion of metoclopramide (Reglan) 10 mg IV. Obtain a urine specimen for urinalysis. Start an infusion of 0.9% normal saline at 100 mL/hr.

Administer morphine sulfate 4 mg IV. - The intervention the nurse implements first for a client admitted with urolithiasis who reports "spasms of intense flank pain, nausea, and severe dizziness" is to administer morphine sulfate 4 mg IV. *Morphine administered intravenously will decrease the pain and the associated sympathetic nervous system reactions of nausea and hypotension.* - An infusion of metoclopramide (Reglan) 10 mg IV would be begun AFTER the client's pain is controlled. - A urine specimen for urinalysis would be obtained and an infusion of 0.9% normal saline at 100 mL/hr would be started AFTER the client's pain is controlled.

Which nursing actions are important in the management of a patient with an arteriovenous (AV) fistula? *Select all that apply.* Auscultate the bruit. Palpate the thrill. Draw all laboratory work from the fistula. Avoid constrictive clothing on the limb containing the access. Take blood pressure (BP) measurements in the fistula arm.

Auscultate the bruit, palpate the thrill, and avoid constricting clothing on the access limb. - Laboratory work should NOT be drawn from the fistula, and the blood pressure (BP) measurements should NOT be taken in the arm with the fistula.

A 25-year-old sexually active female client diagnosed with cystitis tells the nurse that she doesn't understand why she has these infections yearly because she tries to avoid them by drinking very little at work so she doesn't have to use the "dirty" public toilet. Which suggestions or actions by the nurse are most likely to help this client reduce her risk for cystitis? *Select all that apply.* A. Reinforce her choice to avoid using a public toilet. B. Teach her to shower immediately after having sexual intercourse. C. Suggest that she drink at least 2-3 L of fluid throughout the day. D. Urge her to change her method of birth control from oral contraceptives to a barrier method. E. Instruct her to always wipe her perineum from front to back after each toilet use. F. Reinforce that she should complete the entire course of antibiotics as prescribed. G. Instruct her to empty her bladder immediately before having intercourse.

C, E, F, G - A is incorrect because using a public toilet, even sitting on the seat, does not lead to cystitis or a UTI. - Showering after intercourse does NOT affect the development of UTIs. Showering BEFORE intercourse can reduce the number of perineal organisms and reduce the risk for UTI. - *Oral contraceptives do not increase the risk for UTI; however, some barrier methods (especially a cervical cap or diaphragm) can increase because of the increased manipulation of tissues in the area.* - Drinking more fluids throughout the day dilute the urine and increase the frequency of urination, and both responses help reduce the number of organisms in the bladder. - *Wiping the perineum from front to back prevents organisms around the anus and vagina from being translocated to the area around the urethra.* - Completing the antibiotics prescribed for a current UTI helps eradicate the organism and prevent recurrence with resistant organisms. - Emptying the bladder before intercourse decreases the risk for reflux from the bladder into the ureters from external pressure

An older adult client diagnosed with urge incontinence is prescribed the medication oxybutynin (Ditropan). Which side effects does the nurse tell the client to expect? *Select all that apply.* Dry mouth Increased blood pressure Constipation Increased intraocular pressure Reddish-orange urine color

Dry mouth, Constipation, Increased intraocular pressure - Urge incontinence is the loss of urine for no apparent reason after suddenly feeling the need or urge to urinate. Side effects of oxybutynin (Anti-Cholinergic) prescribed for urge incontinence include: dry mouth, constipation, and increased intraocular pressure with the potential to make glaucoma worse. Oxybutynin is an anticholinergic/antispasmodic medication.

The nurse is teaching a group of older adult women about the signs and symptoms of urinary tract infection (UTI). Which concepts does the nurse explain in the presentation? *Select all that apply.* Dysuria Enuresis Frequency Nocturia Urgency Polyuria

Dysuria, Frequency, Nocturia, Urgency - *The signs and symptoms of UTI include: dysuria (pain or burning with urination), frequency, nocturia (frequent urinating at night), and urgency (having the urge to urinate quickly).* - Enuresis (bed-wetting) and polyuria (increased amounts of urine production) are not signs of a UTI.

A cognitively impaired client has urge incontinence. Which method for achieving continence does the nurse include in the client's care plan? Bladder training Credé method Habit training Kegel exercises

Habit training - *Habit training (scheduled toileting) will be most effective in reducing incontinence for a cognitively impaired client because the caregiver is responsible for helping the client to a toilet on a scheduled basis.* - Bladder training, the Credé method, and learning Kegel exercises require that the client be alert, cooperative, and able to assist with his or her own training.

A patient has a serum creatinine of 0.9 mg/dL at 7:00 this morning. The nurse on the second shift, 12 hours later, notes that the serum creatinine is now 1.8 mg/dL and that the patient's urine output for the previous 12 hours has been 35 mL/h. The patient weighs 93 kg. Acute kidney injury (AKI) is suspected. Using the RIFLE acronym, this patient's data represents what stage of acute kidney dysfunction? Risk Injury Failure Loss

Injury - Risk is indicated by a serum creatinine increased 1.5 times above normal or a serum creatinine increased greater than or equal to 0.3 mg/dL; urine output is less than 0.5 mL/kg/h for 6 hours. - *Injury is indicated by a serum creatinine increased two times above normal;* urine output is less than 0.5 mL/kg/h for 12 hours. - *Failure is indicated by a serum creatinine increased three times above normal,* a serum creatinine greater than or equal to 4 mg/dL, or a serum creatinine acute increased greater than or equal to 0.5 mg/dL; urine output is less than 0.3 mL/kg/h for 24 hours or anuria for 12 hours (oliguria). - Loss is indicated by persistent acute kidney injury (AKI) or complete loss of kidney function for more than 4 weeks.

AKI: Intrarenal causes

Kidney damage (Hint: Think stuff that happens *inside* the kidney) - Damage to *kidney tissue* is classed as intrarenal or intrinsic renal failure and reflects *injury to the glomeruli, nephrons, or tubules.*

Hypophosphatemia is characterized by what clinical findings? Vomiting, spasticity, altered mentation Anorexia, decreased platelet aggregation, postural hypotension Nausea, hemolytic anemia, depressed white cell function Diarrhea, cardiac dysrhythmias, deep bone pain *Normal phosphate levels?*

Nausea, hemolytic anemia, depressed white cell function - *Hypophosphatemia is considered to be a phosphorous level less than 3 mg/dL and is characterized by hemolytic anemias, depressed white blood cell function, bleeding (decreased platelet aggregation), nausea, and vomiting.* - *The normal range for phosphorous is 3-4.5 mg/dL.*

Which nursing intervention or practice is most effective in helping to prevent urinary tract infection (UTI) in hospitalized clients? Encouraging them to drink fluids Irrigating all catheters daily with sterile saline Recommending that catheters be placed in all clients Periodically reevaluating the need for indwelling catheters

Periodically reevaluating the need for indwelling catheters - *The nursing intervention that is most effective is helping to prevent UTIs in hospitalized clients is periodically reevaluating the need for indwelling catheters.* Studies have shown that this intervention is the best way to prevent UTIs in the hospital setting. - Encouraging fluids, although it is a valuable practice for clients with catheters, will not necessarily prevent the occurrence of UTIs in the hospital setting. In some clients, their conditions do not permit an increase in fluids, such as those with congestive heart failure and kidney failure. - *Irrigating catheters daily is contraindicated, because any time a closed system is opened, bacteria may be introduced.* - Placing catheters in all clients is unnecessary and unrealistic. This practice would place more clients at risk for the development of UTI.

Which nursing activity illustrates proper aseptic technique during catheter care? Applying Betadine ointment to the perineal area after catheterization Irrigating the catheter daily Positioning the collection bag below the height of the bladder Sending a urine specimen to the laboratory for testing

Positioning the collection bag below the height of the bladder - Proper aseptic technique during catheter care involves positioning the collection bag below the height of the bladder. *Urine collection bags must be kept below the level of the bladder at all times. Elevating the collection bag above the bladder causes reflux of pathogens from the bag into the urinary tract.* - Applying antiseptic solutions or antibiotic ointments to the perineal area of catheterized clients has not demonstrated any beneficial effect. - A closed system of irrigation must be maintained by *ensuring that catheter tubing connections are sealed securely; disconnections can introduce pathogens into the urinary tract, so routine catheter irrigation would be avoided.* - Sending a urine specimen to the laboratory is not indicated for asepsis.

A client who is 6 months pregnant comes to the prenatal clinic with a suspected urinary tract infection (UTI). What action does the nurse take with this client? Discharges the client to her home for strict bedrest for the duration of the pregnancy Instructs the client to drink a minimum of 3 liters of fluids, especially water, every day to "flush out" bacteria Recommends that the client refrain from having sexual intercourse until after she has delivered her baby Refers the client to the clinic nurse practitioner for immediate follow-up

Refers the client to the clinic nurse practitioner for immediate follow-up - When a client who is 6 months pregnant comes to the prenatal clinic with a suspected UTI, the nurse needs to refer the client to the clinic nurse practitioner for immediate follow-up. - *Pregnant women with UTIs require prompt and aggressive treatment because simple cystitis can lead to acute pyelonephritis. This in turn can cause preterm labor with adverse effects for the fetus.* - It is unsafe for the client to be sent home without analysis of the symptoms that she has. Her problem needs to be investigated without delay. - Although drinking increased amounts of fluids is helpful, it will not cure an infection. Having sexual intercourse (or not having it) is not related to the client's problem. The client's symptoms need follow-up with a primary health care provider.

Which type of incontinence benefits from pelvic floor muscle (Kegel) exercise? Functional Overflow Stress Urge

Stress - Stress incontinence benefits the most from pelvic floor (Kegel) exercise therapy. *For women with stress incontinence, Kegel therapy strengthens the muscles of the pelvic floor, thereby helping decrease the occurrence of incontinence.* - Functional incontinence is not caused by a weakened pelvic floor. It is due to structural problems often resulting from injury or trauma. - Overflow incontinence is caused by too much urine being stored in the bladder. - Urge incontinence is caused by a problem (i.e., neurologic) with the client's urge to urinate.

The certified Wound, Ostomy, and Continence Nurse or enterostomal therapist teaches a client who has had a cystectomy about which care principles for the client's postdischarge activities? Nutritional and dietary care Respiratory care Stoma and pouch care Wiping from front to back (asepsis)

Stoma and pouch care - The enterostomal therapist teaches the client who had a cystectomy about stoma and pouch care. *The therapist demonstrates external pouch application, local skin care, pouch care, methods of adhesion, and drainage mechanisms.* - The registered dietitian teaches the cystectomy client about nutritional care. - The respiratory therapist teaches the cystectomy client about respiratory care. - The client with a cystectomy does not require instruction about front-to-back wiping.

A 32-year-old female with a urinary tract infection (UTI) reports urinary frequency, urgency, and some discomfort upon urination. Her vital signs are stable except for a temperature of 100°F (37.8°C). Which drug does the primary health care provider prescribe? Nitrofurantoin (Macrodantin) after intercourse Estrogen (Premarin) Trimethoprim/sulfamethoxazole (Bactrim) Phenazopyridine (Pyridium) with intercourse

Trimethoprim/sulfamethoxazole (Bactrim) - The primary health care provider prescribes trimethoprim/sulfamethoxazole to a 32-year-old woman with a UTI who reports urinary frequency, urgency, and some discomfort upon urination. *Guidelines indicate that a 3-day course of trimethoprim/sulfamethoxazole is effective in treating uncomplicated, community-acquired UTI in women.* - Drugs from the same class as nitrofurantoin reduce bacteria in the urinary tract by inhibiting bacterial reproduction (bacteriostatic action). This client needs a drug that will kill bacteria. Estrogen cream may help prevent recurrent UTIs in postmenopausal women, which this client is not (at age 32). - *Use of Premarin is related to problems with incontinence.* - Phenazopyridine (Pyridium) is not used to treat infection, but symptoms of a UTI.