Med-Surg Agency II_GU NCLEX

The nurse is assessing a client diagnosed with cystitis. To percuss the kidneys, the nurse locates the costovertebral angle, which is formed by the spinal column and rib number: Answer:

12 RATIONALES: Kidney percussion is done to check for costovertebral angle tenderness that occurs with inflammation. Percussing over the kidneys is done with the client sitting down. The nurse should place the ball of her nondominant hand on the client's back at the costovertebral angle — the angle formed by the spinal column and the 12th rib. The nurse should then strike the ball of her hand with the ulnar surface of her other hand and percuss bilaterally. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

The nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point would the nurse want to include? 1. Limit fluid intake to reduce the need to urinate. 2. Take medication prescribed for a UTI until the symptoms subside. 3. Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. 4. Wear only nylon underwear to reduce the chance of irritation.

3

Which statement best describes the therapeutic action of loop diuretics? 1. They block reabsorption of potassium on the collecting tubule. 2. They promote sodium secretion into the distal tubule. 3. They block sodium reabsorption in the ascending loop and dilate renal vessels. 4. They promote potassium secretion into the distal tubule and constrict renal vessels.

3 RATIONALES: Loop diuretics block sodium reabsorption in the ascending loop of Henle, which promotes water diuresis. They also dilate renal vessels. Loop diuretics block potassium reabsorption, but this isn't a therapeutic effect. Thiazide diuretics promote sodium secretion into the distal tubule. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension

he client is scheduled for urinary diversion surgery to treat bladder cancer. Before surgery, the health care team consisting of a nurse, dietician, social worker, enterostomal therapist, surgeon, client educator, and mental health worker meet with the client. After the meeting, the client states, "My life won't ever be the same. What am I going to do?" Which health team member should the nurse consult to help with the client's concerns? 1. Social worker 2. Surgeon 3. Dietician 4. Client educator

4 RATIONALES: The nurse should consult the client educator to help the client with his fears and concerns. Providing the client with information can greatly allay the client's fears. The social worker can provide the client with services he may need after discharge. The dietician can help with dietary concerns but can't provide help with direct concerns about the surgery. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

The nurse is providing inservice education for the staff about evidence collection after sexual assault. The educational session is successful when the staff focuses their initial care on which step? 1. Collecting semen 2. Performing the pelvic examination 3. Obtaining consent for examination 4. Supporting the client's emotional status

4 RATIONALES: The teaching session is successful when the nurses focus on supporting the client's emotional status first. Next, the nurses should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Application

Which of the following is an appropriate nursing diagnosis for a client with renal calculi? 1. Ineffective renal tissue perfusion 2. Functional urinary incontinence 3. Risk for infection 4. Decreased cardiac output

3 RATIONALES: Infection can occur with renal calculi from urine stasis caused by obstruction. Options 1 and 4 aren't appropriate for this client, and retention of urine, rather than incontinence, usually occurs. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client with heart failure admitted to an acute care facility and is found to have a cystocele. When planning care for this client, the nurse is most likely to formulate which nursing diagnosis? 1. Total urinary incontinence 2. Functional urinary incontinence 3. Reflex urinary incontinence 4. Stress urinary incontinence

4 RATIONALES: Stress urinary incontinence is a urinary problem associated with cystocele — herniation of the bladder into the birth canal. Other problems associated with this disorder include urinary frequency, urinary urgency, urinary tract infection (UTI), and difficulty emptying the bladder. Total incontinence, functional incontinence, and reflex incontinence usually result from neurovascular dysfunction, not cystocele. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension

The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which nursing intervention is appropriate? 1. Tell the client to try to urinate around the catheter to remove blood clots. 2. Restrict fluids to prevent the client's bladder from becoming distended. 3. Prepare to remove the catheter. 4. Use aseptic technique when irrigating the catheter.

RATIONALES: If the catheter is blocked by blood clots, it may be irrigated according to physician's orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. Encourage the client to drink fluids to dilute the urine and maintain urine output. The catheter remains in place for 2 to 4 days after surgery and is only removed with a physician's order. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? 1. Acute pain 2. Risk for infection 3. Impaired urinary elimination 4. Imbalanced nutrition: Less than body requirements

1 RATIONALES: Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority. Diagnoses of Risk for infection and Impaired urinary elimination are appropriate when the client's pain is controlled. A diagnosis of Imbalanced nutrition: Less than body requirements isn't pertinent at this time. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

A client with a history of chronic cystitis comes to the outpatient clinic with signs and symptoms of this disorder. To prevent cystitis from recurring, the nurse recommends maintaining an acid-ash diet to acidify the urine, thereby decreasing the rate of bacterial multiplication. On an acid-ash diet, the client must restrict which beverage? 1. Cranberry juice 2. Coffee 3. Prune juice 4. Milk

4 RATIONALES: A client on an acid-ash diet must avoid milk and milk products because these make the urine more alkaline, encouraging bacterial growth. Other foods to avoid on this diet include all vegetables except corn and lentils; all fruits except cranberries, plums, and prunes; and any food containing large amounts of potassium, sodium, calcium, or magnesium. Cranberry and prune juice are encouraged because they acidify the urine. Coffee and tea are considered neutral because they don't alter the urine pH. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Comprehension

When performing a scrotal examination, the nurse finds a nodule. What should the nurse do next? 1. Notify the physician. 2. Change the client's position and repeat the examination. 3. Perform a rectal examination. 4. Transilluminate the scrotum.

4 RATIONALES: A nurse who discovers a nodule, swelling, or other abnormal finding during a scrotal examination should transilluminate the scrotum by darkening the room and shining a flashlight through the scrotum behind the mass. A scrotum filled with serous fluid transilluminates as a red glow; a more solid lesion, such as a hematoma or mass, doesn't transilluminate and may appear as a dark shadow. Although the nurse should notify the physician of the abnormal finding, performing transillumination first provides additional information. The nurse can't uncover more information about a scrotal mass by changing the client's position and repeating the examination or by performing a rectal examination. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure? 1. Poor perfusion to the kidneys 2. Damage to cells in the adrenal cortex 3. Obstruction of the urinary collecting system 4. Nephrotoxic injury secondary to use of contrast media

4 RATIONALES: Intrinsic renal failure results from damage to the kidney, such as from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or bacterial toxins. Poor perfusion to the kidneys may result in prerenal failure. Damage to the epithelial cells of the renal tubules results from nephrotoxic injury, not damage to the adrenal cortex. Obstruction of the urinary collecting system may cause postrenal failure. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client is frustrated and embarrassed by urinary incontinence. Which measure should the nurse include in a bladder retraining program? 1. Establishing a predetermined fluid intake pattern for the client 2. Encouraging the client to increase the time between voidings 3. Restricting fluid intake to reduce the need to void 4. Assessing present elimination patterns

4 RATIONALES: The guidelines for initiating bladder retraining include assessing the client's intake patterns, voiding patterns, and reasons for each accidental voiding. Lowering the client's fluid intake won't reduce or prevent incontinence. The client should actually be encouraged to drink 1.5 to 2 L of water per day. A voiding schedule should be established after assessment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

A client with acute renal failure is undergoing dialysis for the first time. The nurse monitors the client closely for dialysis equilibrium syndrome, a complication that is most common during the first few dialysis sessions. Typically, dialysis equilibrium syndrome causes: 1. confusion, headache, and seizures. 2. acute bone pain and confusion. 3. weakness, tingling, and cardiac arrhythmias. 4. hypotension, tachycardia, and tachypnea.

1 RATIONALES: Dialysis equilibrium syndrome causes confusion, a decreasing level of consciousness, headache, and seizures. These findings, which may last several days, probably result from a relative excess of interstitial or intracellular solutes caused by rapid solute removal from the blood. The resultant organ swelling interferes with normal physiological functions. To prevent this syndrome, many dialysis centers keep first-time sessions short and use a reduced blood flow rate. Acute bone pain and confusion are associated with aluminum intoxication, another potential complication of dialysis. Weakness, tingling, and cardiac arrhythmias suggest hyperkalemia, which is associated with renal failure. Hypotension, tachycardia, and tachypnea signal hemorrhage, another dialysis complication. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

A client is admitted for treatment of chronic renal failure (CRF). The nurse knows that this disorder increases the client's risk of: 1. water and sodium retention secondary to a severe decrease in the glomerular filtration rate. 2. a decreased serum phosphate level secondary to kidney failure. 3. an increased serum calcium level secondary to kidney failure. 4. metabolic alkalosis secondary to retention of hydrogen ions.

1 RATIONALES: A client with CRF is at risk for fluid imbalance — dehydration if the kidneys fail to concentrate urine, or fluid retention if the kidneys fail to produce urine. Electrolyte imbalances associated with this disorder result from the kidneys' inability to excrete phosphorus; such imbalances may lead to hyperphosphatemia with reciprocal hypocalcemia. CRF may cause metabolic acidosis, not metabolic alkalosis, secondary to inability of the kidneys to excrete hydrogen ions. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir). Which statement by the client indicates a need for further teaching? 1. "I'll have to wear an external collection pouch for the rest of my life." 2. "I should eat foods from all the food groups." 3. "I'll need to drink at least eight glasses of water a day." 4. "I'll have to catheterize my pouch every 2 hours."

1 RATIONALES: An internal collection pouch, such as the Kock pouch, allows the client to perform self-catheterization for ileal drainage. This pouch is an internal reservoir, eliminating the need for an external collection pouch. A well-balanced diet is essential for healing; the client need not include or exclude particular foods. The client should drink at least eight glasses of fluid daily to prevent calculi formation and urinary tract infection (UTI). Intervals between pouch drainings should be increased gradually until the pouch is emptied two to four times daily. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

A client develops acute renal failure (ARF) after receiving I.V. therapy with a nephrotoxic antibiotic. Because the client's 24-hour urine output totals 240 ml, the nurse suspects that the client is at risk for: 1. cardiac arrhythmia. 2. paresthesia. 3. dehydration. 4. pruritus.

1 RATIONALES: As urine output decreases, the serum potassium level rises; if it rises sufficiently, hyperkalemia may occur, possibly triggering a cardiac arrhythmia. Hyperkalemia doesn't cause paresthesia (sensations of numbness and tingling). Dehydration doesn't occur during this oliguric phase of ARF, although typically it does arise during the diuretic phase. In a client with ARF, pruritus results from increased phosphates and isn't associated with hyperkalemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

When caring for a client with acute renal failure (ARF), the nurse expects to adjust the dosage or dosing schedule of certain drugs. Which of the following drugs would not require such adjustment? 1. acetaminophen (Tylenol) 2. gentamicin sulfate (Garamycin) 3. cyclosporine (Sandimmune) 4. ticarcillin disodium (Ticar)

1 RATIONALES: Because acetaminophen is metabolized in the liver, its dosage and dosing schedule need not be adjusted for a client with ARF. In contrast, the dosages and schedules for gentamicin and ticarcillin, which are metabolized and excreted by the kidney, should be adjusted. Because cyclosporine may cause nephrotoxicity, the nurse must monitor both the dosage and blood drug level in a client receiving this drug. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Knowledge

A 75-year-old client with renal insufficiency is admitted to the hospital with pneumonia. He's being treated with gentamicin (Garamycin), which can be nephrotoxic. Which laboratory value should be closely monitored? 1. Blood urea nitrogen 2. Sodium level 3. Alkaline phosphatase 4. White blood cell (WBC) count

1 RATIONALES: Blood urea nitrogen and creatinine levels should be closely monitored to detect elevations caused by nephrotoxicity. Sodium level should be routinely monitored in all hospitalized clients. Alkaline phosphatase helps evaluate liver function. The WBC count should be monitored to evaluate the effectiveness of the antibiotic; it doesn't help evaluate kidney function. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

The nurse is caring for a client who had a stroke. Which nursing intervention promotes urinary continence? 1. Encouraging intake of at least 2 L of fluid daily 2. Giving the client a glass of soda before bedtime 3. Taking the client to the bathroom twice per day 4. Consulting with a dietitian

1 RATIONALES: By encouraging a daily fluid intake of at least 2 L, the nurse helps fill the client's bladder, thereby promoting bladder retraining by stimulating the urge to void. The nurse shouldn't give the client soda before bedtime; soda acts as a diuretic and may make the client incontinent. The nurse should take the client to the bathroom or offer the bedpan at least every 2 hours throughout the day; twice per day is insufficient. Consultation with a dietitian won't address the problem of urinary incontinence. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Comprehension

A client is admitted for treatment of glomerulonephritis. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include: 1. generalized edema, especially of the face and periorbital area. 2. green-tinged urine. 3. moderate to severe hypotension. 4. polyuria.

1 RATIONALES: Generalized edema, especially of the face and periorbital area, is a classic sign of acute glomerulonephritis of sudden onset. Other classic signs and symptoms of this disorder include hematuria (not green-tinged urine), proteinuria, fever, chills, weakness, pallor, anorexia, nausea, and vomiting. The client also may have moderate to severe hypertension (not hypotension), oliguria or anuria (not polyuria), headache, reduced visual acuity, and abdominal or flank pain. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

The nurse is planning to administer a sodium polystyrene sulfonate (Kayexalate) enema to a client with a potassium level of 6.2 mEq/L. Correct administration and the effects of this enema would include having the client: 1. retain the enema for 30 minutes to allow for sodium exchange; afterward, the client should have diarrhea. 2. retain the enema for 30 minutes to allow for glucose exchange; afterward, the client should have diarrhea. 3. retain the enema for 60 minutes to allow for sodium exchange; diarrhea isn't necessary to reduce the potassium level. 4. retain the enema for 60 minutes to allow for glucose exchange; diarrhea isn't necessary to reduce the potassium level.

1 RATIONALES: Kayexalate is a sodium-exchange resin. Thus, the client will gain sodium as potassium is lost in the bowel. For the exchange to occur, Kayexalate must be in contact with the bowel for at least 30 minutes. Sorbitol in the Kayexalate enema causes diarrhea, which increases potassium loss and decreases the potential for Kayexalate retention. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension

During rounds, a client admitted with gross hematuria asks the nurse about the physician's diagnosis. To facilitate effective communication, what should the nurse do? 1. Ask why the client is concerned about the diagnosis. 2. Change the subject to something more pleasant. 3. Provide privacy for the conversation. 4. Give the client some good advice.

1 RATIONALES: Providing privacy for the conversation is a form of active listening, which focuses solely on the client's needs. Asking why the client is concerned, changing the subject, or giving advice tends to block therapeutic communication. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client with benign prostatic hyperplasia doesn't respond to medical treatment and is admitted to the facility for prostate gland removal. Before providing preoperative and postoperative instructions to the client, the nurse asks the surgeon which prostatectomy procedure will be done. What is the most widely used procedure for prostate gland removal? 1. Transurethral resection of the prostate (TURP) 2. Suprapubic prostatectomy 3. Retropubic prostatectomy 4. Transurethral laser incision of the prostate

1 RATIONALES: TURP is the most widely used procedure for prostate gland removal. Because it requires no incision, TURP is especially suitable for men with relatively minor prostatic enlargements and for those who are poor surgical risks. Suprapubic prostatectomy, retropubic prostatectomy, and transurethral laser incision of the prostate are less common procedures; they all require an incision. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

A client with a genitourinary problem is being examined in the emergency department. When palpating the client's kidneys, the nurse should keep in mind which anatomic fact? 1. The left kidney usually is slightly higher than the right one. 2. The kidneys are situated just above the adrenal glands. 3. The average kidney is approximately 5 cm (2″) long and 2 to 3 cm (¾″ to 1-1/8″) wide. 4. The kidneys lie between the 10th and 12th thoracic vertebrae.

1 RATIONALES: The left kidney usually is slightly higher than the right one. An adrenal gland lies atop each kidney. The average kidney measures approximately 11 cm (4-3/8″) long, 5 to 5.8 cm (2″ to 2¼″) wide, and 2.5 cm (1″) thick. The kidneys are located retroperitoneally, in the posterior aspect of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and 3rd lumbar vertebrae. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client comes to the emergency department complaining of sudden onset of sharp, severe pain in the lumbar region, which radiates around the side and toward the bladder. The client also reports nausea and vomiting and appears pale, diaphoretic, and anxious. The physician tentatively diagnoses renal calculi and orders flat-plate abdominal X-rays. Renal calculi can form anywhere in the urinary tract. What is their most common formation site? 1. Kidney 2. Ureter 3. Bladder 4. Urethra

1 RATIONALES: The most common site of renal calculi formation is the kidney. Calculi may travel down the urinary tract with or without causing damage and may lodge anywhere along the tract or may stay within the kidney. The ureter, bladder, and urethra are less common sites of renal calculi formation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes neck vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take? 1. Place the client on bed rest. 2. Provide a high-protein, fluid-restricted diet. 3. Prepare to assist with insertion of a Tenckhoff catheter for hemodialysis. 4. Place the client on a sheepskin, and monitor for increasing edema.

1 RATIONALES: The nurse immediately must enforce bed rest for a client with glomerulonephritis to ensure a complete recovery and help prevent complications. Depending on disease severity, the client may require fluid, sodium, potassium, and protein restrictions. Because of the risk of altered urinary elimination related to oliguria, this client may require hemodialysis or plasmapheresis for several weeks until renal function improves; however, a Tenckhoff catheter is used in peritoneal dialysis, not hemodialysis. Although comfort measures such as placing the client on a sheepskin are important, they don't take precedence. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

After undergoing renal arteriogram, in which the left groin was accessed, the client complains of left calf pain. Which intervention should the nurse perform first? 1. Assess peripheral pulses in the left leg. 2. Place cool compresses on the calf. 3. Exercise the leg and foot. 4. Assess for anaphylaxis.

1 RATIONALES: The nurse should begin by assessing peripheral pulses in the left leg to determine if blood flow was interrupted by the procedure. The client may also have thrombophlebitis. Cool compresses aren't used to relieve pain and inflammation in thrombophlebitis. The leg should remain straight after the procedure. Calf pain isn't a symptom of anaphylaxis. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

he nurse is caring for a 25-year-old female client diagnosed with a chlamydia infection. The nurse teaches the client about disease transmission and advises the client to inform her sexual partners of the infection. The client refuses, stating, "This is my business and I'm not telling anyone. Beside, chlamydia doesn't cause any harm like the other STDs." How should the nurse proceed? 1. Educate the client about why it's important to inform sexual contacts so they can receive treatment. 2. Inform the health department that this client contracted a sexually transmitted disease. 3. Inform the client's sexual contacts of their possible exposure to chlamydia. 4. Do nothing because the client's sexual habits place her at risk for contracting other sexually transmitted diseases.

1 RATIONALES: The nurse should educate the client about the disease and how it impacts a person's health. Further education allows the client to make an informed decision about notifying sexual contacts. The nurse must maintain client confidentiality unless law mandates reporting the illness; contacting sexual contacts breeches client confidentiality. Option 4 is judgmental; everyone is entitled to health care regardless of their health habits. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application

The client is prescribed continuous bladder irrigation at a rate of 60 gtt/minute. The nurse hangs a 2 L bag of sterile solution with tubing on a three-legged I.V. pole. She then attaches the tubing to the client's three-way urinary catheter, adjusts the flow rate, and leaves the room. Which important procedural step did the nurse fail to follow? 1. Evaluating patency of the drainage lumen 2. Counter-balancing the I.V. pole 3. Attaching the infusion set to an infusion pump 4. Collecting a urine specimen before beginning irrigation

1 RATIONALES: The nurse should evaluate patency of the drainage tubing before leaving the client's room. If the lumen is obstructed, the solution infuses into the bladder but isn't eliminated through the drainage tubing, a situation that may cause client injury. Balancing the pole is important; however, the nurse would have had to address this issue immediately after hanging the 2 L bag. Using an I.V. pump isn't necessary for continuous bladder irrigation. Unless specifically ordered, obtaining a urine specimen before beginning continuous bladder irrigation isn't necessary. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

A client is scheduled for a renal clearance test. The nurse should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in: 1. 1 minute. 2. 30 minutes. 3. 1 hour. 4. 24 hours.

1 RATIONALES: The renal clearance test determines the kidneys' ability to remove a substance from the plasma in 1 minute. It doesn't measure the kidneys' ability to remove a substance over a longer period. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Knowledge

A client reports experiencing vulvar pruritus. Which assessment factor may indicate that the client has an infection caused by Candida albicans? 1. Cottage cheese-like discharge 2. Yellow-green discharge 3. Gray-white discharge 4. Discharge with a fishy odor

1 RATIONALES: The symptoms of C. albicans include itching and a scant white discharge that has the consistency of cottage cheese. Yellow-green discharge is a sign of Trichomonas vaginalis. Gray-white discharge and a fishy odor are signs of Gardnerella vaginalis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

A client returns to the medical-surgical unit after coronary artery bypass graft surgery, which was complicated by prolonged cardiopulmonary bypass and hypotension. After 3 hours in the unit, the client's condition stabilizes. However, the urine output has decreased despite adequate filling pressures. The nurse expects the physician to add which drug, at which flow rate, to the client's regimen? 1. Dopamine (Intropin), 3 mcg/kg/min 2. Epinephrine, 2 mcg/kg/min 3. Dopamine (Intropin), 8 mcg/kg/min 4. Epinephrine, 4 mcg/kg/min

1 RATIONALES: This client is at high risk for acute prerenal failure secondary to decreased renal perfusion during surgery. To dilate the renal arteries and help prevent renal shutdown, the physician is likely to prescribe dopamine at a low flow rate (2 to 5 mcg/kg/min). Although this drug has mixed dopaminergic and beta activity when given at 5 to 10 mcg/kg/min, the client is stabilized and thus doesn't need the beta effects from the higher flow rate — or the sympathomimetic effects of epinephrine. The dopaminergic effects of dopamine increase renal perfusion, contractility, and vasodilation. Stimulation of beta receptors causes beta effects — namely, increases in the heart rate, myocardial contraction force, and cardiac conduction. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Knowledge

A triple-lumen indwelling urinary catheter is inserted for continuous bladder irrigation following a transurethral resection of the prostate. In addition to balloon inflation, the functions of the three lumens include: 1. continuous inflow and outflow of irrigation solution. 2. intermittent inflow and continuous outflow of irrigation solution. 3. continuous inflow and intermittent outflow of irrigation solution. 4. intermittent flow of irrigation solution and prevention of hemorrhage.

1 RATIONALES: When preparing for continuous bladder irrigation, a triple-lumen indwelling urinary catheter is inserted. The three lumens provide for balloon inflation and continuous inflow and outflow of irrigation solution. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client? 1. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually. 2. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days. 3. The potential for transmission to her sexual partner will be eliminated if condoms are used every time she and her partner have sexual intercourse. 4. The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitt

1 RATIONALES: Women with condylomata acuminata are at risk for cancer of the cervix and vulva. Yearly Pap smears are very important for early detection. Because condylomata acuminata is a virus, there is no permanent cure. Because condylomata acuminata can occur on the vulva, a condom won't protect sexual partners. HPV can be transmitted to other parts of the body, such as the mouth, oropharynx, and larynx. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

After a retropubic prostatectomy, a client needs continuous bladder irrigation. The client has an I.V. of D5W infusing at 40 ml/hr, and a triple-lumen urinary catheter with normal saline solution infusing at 200 ml/hr. The nurse empties the urinary catheter drainage bag three times during an 8-hour period for a total of 2,780 ml. How many milliliters does the nurse calculate as urine? Answer:

1,180 RATIONALES: During 8 hours, 1,600 ml of bladder irrigation has been infused (200 ml × 8 hr = 1,600 ml/8 hr). The nurse then subtracts this amount of infused bladder irrigation from the total volume in the drainage bag (2,780 ml − 1,600 ml = 1,180 ml) to determine urinary output. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis

The nurse is caring for a client with chronic renal failure. The laboratory results indicate hypocalcemia and hyperphosphatemia. When assessing the client, the nurse should be alert for which of the following? 1. Trousseau's sign 2. Cardiac arrhythmias 3. Constipation 4. Decreased clotting time 5. Drowsiness and lethargy 6. Fractures

1,2,6 RATIONALES: Hypocalcemia is a calcium deficit that causes nerve fiber irritability and repetitive muscle spasms. Signs and symptoms of hypocalcemia include Trousseau's sign, cardiac arrhythmias, diarrhea, increased clotting times, anxiety, and irritability. The calcium-phosphorus imbalance leads to brittle bones and pathologic fractures. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client with renal dysfunction of acute onset comes to the emergency department complaining of fatigue, oliguria, and coffee-colored urine. When obtaining the client's history to check for significant findings, the nurse should ask about: 1. chronic, excessive acetaminophen use. 2. recent streptococcal infection. 3. childhood asthma. 4. family history of pernicious anemia.

2 RATIONALES: A skin or upper respiratory infection of streptococcal origin may lead to acute glomerulonephritis. Other infections that may be linked to renal dysfunction include infectious mononucleosis, mumps, measles, and cytomegalovirus. Chronic, excessive acetaminophen use isn't nephrotoxic, although it may be hepatotoxic. Childhood asthma and a family history of pernicious anemia aren't significant history findings for a client with renal dysfunction. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

Which conditions are functions of antidiuretic hormone (ADH)? 1. Sodium absorption and potassium excretion 2. Water reabsorption and urine concentration 3. Water reabsorption and urine dilution 4. Sodium reabsorption and potassium retention

2 RATIONALES: ADH stimulates the renal tubules to reabsorb water, thereby concentrating urine. Aldosterone is responsible for sodium reabsorption and potassium excretion by the kidneys. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

The nurse is caring for a client with acute pyelonephritis. Which nursing intervention is most important? 1. Administering a sitz bath twice per day 2. Increasing fluid intake to 3 L/day 3. Using an indwelling urinary catheter to measure urine output accurately 4. Encouraging the client to drink cranberry juice to acidify the urine

2 RATIONALES: Acute pyelonephritis is a sudden inflammation of the interstitial tissue and renal pelvis of one or both kidneys. Infecting bacteria are normal intestinal and fecal flora that grow readily in urine. Pyelonephritis may result from procedures that involve the use of instruments (such as catheterization, cystoscopy, and urologic surgery) or from hematogenic infection. The most important nursing intervention is to increase fluid intake to 3 L/day. This helps empty the bladder of contaminated urine and prevents calculus formation. Administering a sitz bath would increase the likelihood of fecal contamination. Using an indwelling urinary catheter could cause further contamination. Encouraging the client to drink cranberry juice to acidify urine is helpful but isn't the most important interaction. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client is admitted with a diagnosis of acute renal failure. The nurse should monitor closely for: 1. enuresis. 2. drug toxicity. 3. lethargy. 4. insomnia.

2 RATIONALES: Acute renal failure is characterized by oliguria and rapid accumulation of nitrogen waste in the blood. Kidneys excrete medications, so the nurse should monitor the client closely for drug toxicity. With decreased urinary output or no output, enuresis shouldn't occur. The client will most likely feel lethargic, but this isn't as serious a problem as drug toxicity. The client isn't likely to have insomnia, but, may instead want to sleep most of the time. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Knowledge

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significant problem during this procedure? 1. Blood glucose level of 200 mg/dl 2. White blood cell (WBC) count of 20,000/mm3 3. Potassium level of 3.5 mEq/L 4. Hematocrit (HCT) of 35%

2 RATIONALES: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.5 mEq/L can be treated by adding potassium to the dialysate solution. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

A client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, the nurse knows that the client is most likely to experience: 1. hematuria. 2. weight loss. 3. increased urine output. 4. increased blood pressure.

2 RATIONALES: Because CRF causes loss of renal function, the client with this disorder retains fluid. Hemodialysis removes this fluid, causing weight loss. Hematuria is unlikely to follow hemodialysis because the client with CRF usually forms little or no urine. Hemodialysis doesn't increase urine output because it doesn't correct the loss of kidney function, which severely decreases urine production in this disorder. By removing fluids, hemodialysis decreases rather than increases the blood pressure. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client with chronic renal failure who receives hemodialysis three times weekly has a hemoglobin (Hb) level of 7 g/dl. The most therapeutic pharmacologic intervention would be to administer: 1. ferrous sulfate (Feratab). 2. epoetin alfa (Epogen) 3. filgrastim (Neupogen) 4. enoxaparin (Lovenox)

2 RATIONALES: Chronic renal failure diminishes the production of erythropoietin by the kidneys and leads to a subnormal Hb level. (Normal Hb level is 13 to 18 g/dl in men and 12 to 16 g/dl in women.) An effective pharmacologic treatment for this is epoetin alfa, a recombinant erythropoietin. Because the client's anemia is caused by a deficiency of erythropoietin and not a deficiency of iron, administering ferrous sulfate would be ineffective. Neither filgrastim, a drug used to stimulate neutrophils, nor enoxaparin (low-molecular-weight heparin) will raise the client's Hb level. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Analysis

A client with suspected renal dysfunction is scheduled for excretory urography. The nurse reviews the history for conditions that may warrant changes in client preparation. Normally, a client should be mildly hypovolemic (fluid depleted) before excretory urography. Which history finding would call for the client to be well hydrated instead? 1. Cystic fibrosis 2. Multiple myeloma 3. Gout 4. Myasthenia gravis

2 RATIONALES: Fluid depletion before excretory urography is contraindicated in clients with multiple myeloma, severe diabetes mellitus, and uric acid nephropathy — conditions that can seriously compromise renal function in fluid-depleted clients with reduced renal perfusion. If these clients must undergo excretory urography, they should be well hydrated before the test. Cystic fibrosis, gout, and myasthenia gravis don't necessitate changes in client preparation for excretory urography. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

The physician prescribes norfloxacin (Noroxin), for a client with a urinary tract infection (UTI). The client asks the nurse how long to continue taking the drug. For an uncomplicated UTI, the usual duration of norfloxacin therapy is: 1. 3 to 5 days. 2. 7 to 10 days. 3. 12 to 14 days. 4. 10 to 21 days.

2 RATIONALES: For an uncomplicated UTI, norfloxacin therapy usually lasts 7 to 10 days. Taking the drug for less than 7 days wouldn't eradicate such an infection. Taking it for more than 10 days isn't necessary. Only a client with a complicated UTI must take norfloxacin for 10 to 21 days. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Knowledge

A client comes to the outpatient department complaining of vaginal discharge, dysuria, and genital irritation. Suspecting a sexually transmitted disease (STD), the physician orders diagnostic testing of the vaginal discharge. Which STD must be reported to the public health department? 1. Chlamydia 2. Gonorrhea 3. Genital herpes 4. Human papillomavirus infection

2 RATIONALES: Gonorrhea must be reported to the public health department. Chlamydia, genital herpes, and human papillomavirus infection aren't reportable diseases. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge

A client with bladder cancer has had the bladder removed and an ileal conduit created for urine diversion. While changing this client's pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude? 1. The skin wasn't lubricated before the pouch was applied. 2. The pouch faceplate doesn't fit the stoma. 3. A skin barrier was applied properly. 4. Stoma dilation wasn't performed.

2 RATIONALES: If the pouch faceplate doesn't fit the stoma properly, the skin around the stoma will be exposed to continuous urine flow from the stoma, causing excoriation and red, weeping, and painful skin. A lubricant shouldn't be used because it would prevent the pouch from adhering to the skin. When properly applied, a skin barrier prevents skin excoriation. Stoma dilation isn't performed with an ileal conduit, although it may be done with a colostomy if ordered. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction? 1. "Take your temperature every 4 hours." 2. "Increase your fluid intake to 2 to 3 L per day." 3. "Apply an antibacterial dressing to the incision daily." 4. "Be aware that your urine will be cherry-red for 5 to 7 days."

2 RATIONALES: Increasing fluid intake flushes the renal calculi fragments through — and prevents obstruction of — the urinary system. Measuring temperature every 4 hours isn't needed. Lithotripsy doesn't require an incision. Hematuria may occur for a few hours after lithotripsy but should then disappear. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

The physician enters a computer order for the nurse to irrigate a client's nephrostomy tube every four hours to maintain patency. The nurse irrigates the tube using sterile technique. After irrigating the tube, the nurse decides that she can safely use the same irrigation set for her 8-hour shift if she covers the set with a paper, sterile drape. This action by the nurse is: 1. appropriate because the irrigation just checks for patency. 2. inappropriate because irrigation requires strict sterile technique. 3. appropriate because the irrigation set will only be used during an 8-hour period. 4. inappropriate because the sterile drape must be cloth, not paper.

2 RATIONALES: Irritating a nephrostomy tube requires strict sterile technique; therefore, reusing the irrigation set (even if covered by a sterile drape) is inappropriate. Bacteria can proliferate inside the syringe and irrigation container. Although this procedure checks patency, it requires sterile technique to prevent the introduction of bacteria into the kidney. The material in which the sterile drape is made is irrelevant because a sterile drape doesn't deter bacterial growth in the irrigation equipment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Application

A client is scheduled to undergo surgical creation of an ileal conduit. The primary nurse educates the client about surgery and the postoperative period. The nurse informs the client that many members of the health care team (including a mental health practitioner) will see him. A mental health practitioner should be involved in the client's care to: 1. assess whether the client is a good candidate for surgery. 2. help the client cope with the anxiety associated with changes in body image. 3. assess suicidal risk postoperatively. 4. evaluate the client's need for mental health intervention.

2 RATIONALES: Many clients who undergo surgery for creation of an ileal conduit experience anxiety associated with changes in body image. The mental health practitioner can help with client cope these feelings of anxiety. Mental health practitioners don't evaluate whether the client is a surgical candidate. None of the evidence suggests that urinary diversion surgery, such as creation of an ileal conduit, places the client at risk for suicide. Although evaluating the need for mental health intervention is always important, this client displays no behavioral changes that suggest intervention is necessary at this time. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client with an indwelling urinary catheter is suspected of having a urinary tract infection. The nurse should collect a urine specimen for culture and sensitivity by: 1. disconnecting the tubing from the urinary catheter and letting the urine flow into a sterile container. 2. wiping the self-sealing aspiration port with antiseptic solution and aspirating urine with a sterile needle. 3. draining urine from the drainage bag into a sterile container. 4. clamping the tubing for 60 minutes and inserting a sterile needle into the tubing above the clamp to aspirate urine.

2 RATIONALES: Most catheters have a self-sealing port for obtaining a urine specimen. Antiseptic solution is used to reduce the risk of introducing microorganisms into the catheter. Tubing shouldn't be disconnected from the urinary catheter. Any break in the closed urine drainage system may allow the entry of microorganisms. Urine in urine drainage bags may not be fresh and may contain bacteria, giving false test results. When there is no urine in the tubing, the catheter may be clamped for no more than 30 minutes to allow urine to collect. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

The nurse is reviewing the report of a client's routine urinalysis. Which value should the nurse consider abnormal? 1. Specific gravity of 1.03 2. Urine pH of 3.0 3. Absence of protein 4. Absence of glucose Correct Answer: 2

2 RATIONALES: Normal urine pH is 4.5 to 8; therefore, a urine pH of 3.0 is abnormal. Urine specific gravity normally ranges from 1.002 to 1.035, making this client's value normal. Normally, urine contains no protein, glucose, ketones, bilirubin, bacteria, casts, or crystals. Red blood cells should measure 0 to 3 per high-power field; white blood cells, 0 to 4 per high-power field. Urine should be clear, with color ranging from pale yellow to deep amber. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Analysis

The nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way? 1. Fluid intake should be double the urine output. 2. Fluid intake should be approximately equal to the urine output. 3. Fluid intake should be half the urine output. 4. Fluid intake should be inversely proportional to the urine output.

2 RATIONALES: Normally, fluid intake is approximately equal to the urine output. Any other relationship signals an abnormality. For example, fluid intake that is double the urine output indicates fluid retention; fluid intake that is half the urine output indicates dehydration. Normally, fluid intake isn't inversely proportional to the urine output. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Comprehension

After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? 1. The urine in the drainage bag appears red to pink. 2. The client reports bladder spasms and the urge to void. 3. The normal saline irrigant is infusing at a rate of 50 drops/min. 4. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned.

2 RATIONALES: Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/min or according to facility protocol. The amount of returned fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

The nurse suspects that a client with a temperature of 103.6° F (39.8° C) and an elevated white blood cell count is in the initial stage of sepsis. What is the most common cause of sepsis in hospitalized clients? 1. Respiratory infection 2. Urinary tract infection (UTI) 3. Vasculitis 4. Osteomyelitis

2 RATIONALES: Sepsis most commonly results from a UTI caused by gram-negative bacteria. Other causes of sepsis include infections of the biliary, GI, and gynecologic tracts. Respiratory infection, vasculitis, and osteomyelitis rarely cause sepsis in hospitalized clients. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Knowledge

A client who has cervical cancer is scheduled to undergo internal radiation. In teaching the client about the procedure, the nurse would be most accurate in telling the client: 1. she will be in a private room with unrestricted activities. 2. a bowel-cleansing procedure will precede radioactive implantation. 3. she will be expected to use a bedpan for urination. 4. the preferred position in bed will be semi-Fowler's.

2 RATIONALES: The client will receive an enema before the procedure because bowel motility during cervical radiation implant therapy can disrupt or dislodge the implants. The client will be in a private room, and activities will be restricted in order to keep the implants in place. To keep the bladder empty, an indwelling catheter will be used. Positioning in bed shouldn't exceed a 20-degree elevation because sitting up can cause the implants to move from their intended locations. Semi-Fowler's position is 45 degrees. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

An 85-year-old client is transferred from a local assisted living center to the emergency department with depression and behavioral changes. The nurse notes that the client cries out when she approaches. When the nurse gains the client's confidence and performs an assessment, the nurse notes bruising of the labia and a lateral laceration in the perineal area. When the nurse asks the client about the injury, the client shakes her head and begins to cry "don't tell, don't tell." The nurse suspects sexual abuse. How should the nurse proceed? 1. Notify the physician of her findings immediately. 2. Attend to the client's physiological needs. 3. Notify the client's family. 4. Notify the rape crisis team.

2 RATIONALES: The nurse should attend to the client's immediate physiological needs including physical safety. Next, the nurse can notify the physician and the rape crisis team. The family should be notified if the client consents, but not until the rape investigation is complete. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis

When a client with an indwelling urinary catheter insists on walking to the hospital lobby to visit with family members, the nurse teaches him how to do this without compromising the catheter. Which client action indicates an accurate understanding of this information? 1. The client sets the drainage bag on the floor while sitting down. 2. The client keeps the drainage bag below the bladder at all times. 3. The client clamps the catheter drainage tubing while visiting with the family. 4. The client loops the drainage tubing below its point of entry into the drainage bag.

2 RATIONALES: To maintain effective drainage, the client should keep the drainage bag below the bladder; this allows the urine to flow by gravity from the bladder to the drainage bag. The client shouldn't lay the drainage bag on the floor because it could become grossly contaminated. The client shouldn't clamp the catheter drainage tubing because this impedes the flow of urine. To promote drainage, the client may loop the drainage tubing above — not below — its point of entry into the drainage bag. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

Which clinical finding would the nurse look for in a client with chronic renal failure? 1. Hypotension 2. Uremia 3. Metabolic alkalosis 4. Polycythemia

2 RATIONALES: Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure. Metabolic acidosis results from the inability to excrete hydrogen ions. Anemia results from a lack of erythropoietin. Hypertension (from fluid overload) may or may not be present in chronic renal failure. Hypotension, metabolic alkalosis, and polycythemia aren't present in renal failure. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

Which statement describing urinary incontinence in the elderly is true? 1. Urinary incontinence is a normal part of aging. 2. Urinary incontinence isn't a disease. 3. Urinary incontinence in the elderly can't be treated. 4. Urinary incontinence is a disease.

2 RATIONALES: Urinary incontinence isn't a normal part of aging nor is it a disease. It may be caused by confusion, dehydration, fecal impaction, restricted mobility, or other causes. Certain medications, including diuretics, hypnotics, sedatives, anticholinergics, and antihypertensives, may trigger urinary incontinence. Most clients with urinary incontinence can be treated; some can be cured. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Analysis

The nurse is caring for a male client with gonorrhea. The client asks how he can reduce his risk of contracting another sexually transmitted disease (STD). The nurse should instruct the client to: 1. ask all potential sexual partners if they have a sexually transmitted disease. 2. wear a condom every time he has intercourse. 3. consider intercourse safe if his partner has no visible discharge, lesions, or rashes. 4. expect to limit the number of sexual partners to less than five over his lifetime.

2 RATIONALES: Wearing a condom during intercourse considerably reduces the risk of contracting STDs. The other options may help reduce the risk of contracting an STD but not to the extent wearing a condom will. A monogamous relationship also reduces the risk of contracting STDs. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

A client receiving total parental nutrition is prescribed a 24-hour urine test. When initiating a 24-hour urine specimen, the collection time should: 1. start with the first voiding. 2. start after a known voiding. 3. always be with the first morning urine. 4. always be the evening's last void as the last sample.

2 RATIONALES: When initiating a 24-hour urine specimen, have the client void, then start the timing. The collection should start on an empty bladder. The exact time the test starts isn't important but it's commonly started in the morning. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Knowledge

The nurse is inserting a urinary catheter into a client who is extremely anxious about the procedure. The nurse can facilitate the insertion by asking the client to: 1. initiate a stream of urine. 2. breathe deeply. 3. turn to the side. 4. hold the labia or shaft of the penis.

2 RATIONALES: When inserting a urinary catheter, facilitate insertion by asking the client to breathe deeply. Doing this will relax the urinary sphincter. Initiating a stream of urine isn't recommended during catheter insertion. Turning to the side or holding the labia or penis won't ease insertion, and doing so may contaminate the sterile field. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

A client with a urinary tract infection is prescribed co-trimoxazole (trimethoprim-sulfamethoxazole). The nurse should provide which medication instruction? 1. "Take the medication with food." 2. "Drink at least eight 8-oz glasses of fluid daily." 3. "Avoid taking antacids during co-trimoxazole therapy." 4. "Don't be afraid to go out in the sun."

2 RATIONALES: When receiving a sulfonamide such as co-trimoxazole, the client should drink at least eight 8-oz glasses of fluid daily to maintain a urine output of at least 1,500 ml/day. Otherwise, inadequate urine output may lead to crystalluria or tubular deposits. For maximum absorption, the client should take this drug at least 1 hour before or 2 hours after meals. No evidence indicates that antacids interfere with the effects of sulfonamides. To prevent a photosensitivity reaction, the client should avoid direct sunlight during co-trimoxazole therapy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application

During rectal examination, which finding would be further evidence of a urethral injury? 1. A low-riding prostate 2. The presence of a boggy mass 3. Absent sphincter tone 4. A positive Hemoccult

2 RATIONALES: When the urethra is ruptured, a hematoma or collection of blood separates the two sections of urethra. This may feel like a boggy mass on rectal examination. Because of the rupture and hematoma, the prostate becomes high riding. A palpable prostate gland usually indicates a nonurethral injury. Absent sphincter tone would refer to a spinal cord injury. The presence of blood would probably correlate with GI bleeding or a colon injury. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

A client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing postprocedure care, the nurse should: 1. keep the client's knee on the affected side bent for 6 hours. 2. apply pressure to the puncture site for 30 minutes. 3. check the client's pedal pulses frequently. 4. remove the dressing on the puncture site after vital signs stabilize.

3 RATIONALES: After renal angiography involving a femoral puncture site, the nurse should check the client's pedal pulses frequently to detect reduced circulation to the feet caused by vascular injury. The nurse also should monitor vital signs for evidence of internal hemorrhage and should observe the puncture site frequently for fresh bleeding. The client should be kept on bed rest for several hours so the puncture site can seal completely. Keeping the client's knee bent is unnecessary. By the time the client returns to the short-procedure unit, manual pressure over the puncture site is no longer needed because a pressure dressing is in place. The nurse shouldn't remove this dressing for several hours — and only if instructed to do so. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

After undergoing transurethral resection of the prostate to treat benign prostatic hyperplasia, a client returns to the room with continuous bladder irrigation. On the first day after surgery, the client reports bladder pain. What should the nurse do first? 1. Increase the I.V. flow rate. 2. Notify the physician immediately. 3. Assess the irrigation catheter for patency and drainage. 4. Administer morphine sulfate, 2 mg I.V., as prescribed.

3 RATIONALES: Although postoperative pain is expected, the nurse should make sure that other factors, such as an obstructed irrigation catheter, aren't the cause of the pain. After assessing catheter patency, the nurse should administer an analgesic, such as morphine sulfate, as prescribed. Increasing the I.V. flow rate may worsen the pain. Notifying the physician isn't necessary unless the pain is severe or unrelieved by the prescribed medication. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client with acute pyelonephritis receives a prescription for co-trimoxazole (Septra) P.O. twice daily for 10 days. Which finding best demonstrates that the client has followed the prescribed regimen? 1. Urine output increases to 2,000 ml/day. 2. Flank and abdominal discomfort decrease. 3. Bacteria are absent on urine culture. 4. The red blood cell (RBC) count is normal.

3 RATIONALES: Co-trimoxazole is a sulfonamide antibiotic used to treat urinary tract infections. Therefore, absence of bacteria on urine culture indicates that the drug has achieved its desired effect. Although flank pain may decrease as the infection resolves, this isn't a reliable indicator of the drug's effectiveness. Co-trimoxazole doesn't affect urine output or the RBC count. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important? 1. Encouraging coughing and deep breathing 2. Promoting carbohydrate intake 3. Limiting fluid intake 4. Providing pain-relief measures

3 RATIONALES: During the oliguric phase of ARF, urine output decreases markedly, possibly leading to fluid overload. Limiting oral and I.V. fluid intake can prevent fluid overload and its complications, such as heart failure and pulmonary edema. Encouraging coughing and deep breathing is important for clients with various respiratory disorders. Promoting carbohydrate intake may be helpful in ARF but doesn't take precedence over fluid limitation. Controlling pain isn't important because ARF rarely causes pain. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A client who has been treated for chronic renal failure (CRF) is ready for discharge. The nurse should reinforce which dietary instruction? 1. "Be sure to eat meat at every meal." 2. "Eat plenty of bananas." 3. "Increase your carbohydrate intake." 4. "Drink plenty of fluids, and use a salt substitute."

3 RATIONALES: Extra carbohydrates are needed to prevent protein catabolism. In a client with CRF, unrestricted intake of sodium, protein, potassium, and fluid may lead to a dangerous accumulation of electrolytes and protein metabolic products, such as amino acids and ammonia. Therefore, the client must limit intake of sodium; meat, which is high in protein; bananas, which are high in potassium; and fluid, because the failing kidneys can't secrete adequate urine. Salt substitutes are high in potassium and should be avoided. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

The nurse is caring for a client in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat: 1. hypernatremia. 2. hypokalemia. 3. hyperkalemia. 4. hypercalcemia.

3 RATIONALES: Hyperkalemia is a common complication of acute renal failure. It's life-threatening if immediate action isn't taken to reverse it. The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels. Hypernatremia, hypokalemia, and hypercalcemia don't usually occur with acute renal failure and aren't treated with glucose, insulin, or sodium bicarbonate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

After trying to conceive for a year, a couple consults an infertility specialist. When obtaining a history from the husband, the nurse inquires about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility? 1. Chickenpox 2. Measles 3. Mumps 4. Scarlet fever

3 RATIONALES: Mumps is the childhood infectious disease that most significantly affects male fertility. Chickenpox, measles, and scarlet fever don't affect male fertility. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

The nurse correctly identifies a urine sample with a pH of 4.3 as being which type of solution? 1. Neutral 2. Alkaline 3. Acidic 4. Basic

3 RATIONALES: Normal urine pH is 4.5 to 8.0; a value of 4.3 reveals acidic urine pH. A pH above 7.0 is considered an alkaline or basic solution. A pH of 7.0 is considered neutral. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

Which steps should the nurse follow to insert a straight urinary catheter? 1. Create a sterile field, drape the client, clean the meatus, and insert the catheter only 6". 2. Put on gloves, prepare equipment, create a sterile field, expose the urinary meatus, and insert the catheter 6". 3. Prepare the client and equipment, create a sterile field, put on gloves, clean the urinary meatus, and insert the catheter until urine flows. 4. Prepare the client and equipment, create a sterile field, test the catheter balloon, clean the meatus, and insert the catheter until urine flows.

3 RATIONALES: Option 3 describes all the vital steps for inserting a straight catheter. Option 1 is incorrect because the nurse must prepare the client and equipment before creating a sterile field. Option 2 is incorrect because the nurse put on gloves before creating a sterile field and performing the other tasks. Option 4 describes the procedure for inserting a retention catheter, rather than a straight catheter. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control COGNITIVE LEVEL: Knowledge

Which laboratory value supports a diagnosis of pyelonephritis? 1. Myoglobinuria 2. Ketonuria 3. Pyuria 4. Low white blood cell (WBC) count

3 RATIONALES: Pyelonephritis is diagnosed by the presence of leukocytosis, hematuria, pyuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Because there is often a septic picture, the WBC count is more likely to be high rather than low, as indicated in option 4. Ketonuria indicates a diabetic state. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for: 1. nausea and vomiting. 2. dyspnea and cyanosis. 3. fatigue and weakness. 4. thrush and circumoral pallor.

3 RATIONALES: RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness. Nausea and vomiting may occur in CRF but don't result from faulty RBC production. Dyspnea and cyanosis are associated with fluid excess, not CRF. Thrush, which signals fungal infection, and circumoral pallor, which reflects decreased oxygenation, aren't signs of CRF. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A female client reports to the nurse that she experiences a loss of urine when she jogs. The nurse's assessment reveals no nocturia, burning, discomfort when voiding, or urine leakage before reaching the bathroom. The nurse explains to the client that this type of problem is called: 1. functional incontinence. 2. reflex incontinence. 3. stress incontinence. 4. total incontinence.

3 RATIONALES: Stress incontinence is a small loss of urine with activities that increase intra-abdominal pressure, such as running, laughing, sneezing, jumping, coughing, and bending. These symptoms occur only in the daytime. Functional incontinence is the inability of a usually continent client to reach the toilet in time to avoid unintentional loss of urine. Reflex incontinence is an involuntary loss of urine at predictable intervals when a specific bladder volume is reached. Total incontinence occurs when a client experiences a continuous and unpredictable loss of urine. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Application

To treat a urinary tract infection (UTI), a client is prescribed sulfamethoxazole (Gantanol). The nurse should teach the client that sulfamethoxazole is most likely to cause which adverse effect? 1. Anxiety 2. Headache 3. Diarrhea 4. Dizziness

3 RATIONALES: Sulfamethoxazole is most likely to cause diarrhea. Nausea and vomiting are other common adverse effects. This drug rarely causes anxiety, headache, or dizziness. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Knowledge

The registered nurse and nursing assistant are caring for a group of clients. Which client's care can safely be delegated to the nursing assistant? 1. A 35-year-old client who underwent surgery 12 hours ago and has a suprapubic catheter in place that is draining burgundy colored urine 2. A 63-year-old client with uncontrolled diabetes mellitus who underwent radical suprapubic prostatectomy 1 day ago and has an indwelling urinary catheter draining yellow urine with clots 3. A 45-year-old client diagnosed with renal calculi who must ambulate four times daily and drink plenty of fluids. 4. A 19-year-old client who requires neurological assessment every four hours after sustaining a spinal cord injury in a motor vehicle accident that left him with paraplegia

3 RATIONALES: The care of the client in option 3 can safely be delegated to the nursing assistant. The client in option 1 had surgery 12 hours ago; therefore, the registered nurse should care for the client because the client requires close assessment. The client in option 2 also requires careful assessment by the registered nurse because the client's diabetes mellitus is uncontrolled. In addition, the registered nurse should care for the client in option 4 because the client requires neurological assessment, which isn't within the scope of practice for the nursing assistant. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Analysis

The nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to: 1. limit oral fluid intake for 1 to 2 weeks. 2. report the presence of fine, sandlike particles through the nephrostomy tube. 3. notify the physician about cloudy or foul-smelling urine. 4. report bright pink urine within 24 hours after the procedure.

3 RATIONALES: The client should report the presence of foul-smelling or cloudy urine. Unless contraindicated, the client should be instructed to drink large quantities of fluid each day to flush the kidneys. Sandlike debris is normal because of residual stone products. Hematuria is common after lithotripsy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an I.V. infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that is draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last two consecutive hours. How can the nurse best explain this drop in urine output? 1. It's a normal finding caused by blood loss during surgery. 2. It's a normal finding associated with the client's nothing-by-mouth status. 3. It's an abnormal finding that requires further assessment. 4. It's an abnormal finding that will correct itself when the client ambulates.

3 RATIONALES: The drop in urine output to less than 30 ml/hour is abnormal and requires further assessment. The reduction in urine output may be caused by an obstruction in the urinary catheter tubing or deficient fluid volume from blood loss. The client's nothing-by-mouth status isn't the cause of the low urine output because the client is receiving I.V. fluid to compensate for the lack of oral intake. Ambulation promotes urination; however, the client should produce at least 30 ml of urine/hour. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Analysis

A client with suspected renal insufficiency is scheduled for a comprehensive diagnostic workup. After the nurse explains the diagnostic tests, the client asks which part of the kidney "does the work." Which answer is correct? 1. The glomerulus 2. Bowman's capsule 3. The nephron 4. The tubular system

3 RATIONALES: The nephron is the functioning unit of the kidney. The glomerulus, Bowman's capsule, and tubular system are components of the nephron. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort COGNITIVE LEVEL: Knowledge

A client with chronic renal failure (CRF) is admitted to the urology unit. Which diagnostic test results are consistent with CRF? 1. Increased pH with decreased hydrogen ions 2. Increased serum levels of potassium, magnesium, and calcium 3. Blood urea nitrogen (BUN) 100 mg/dl and serum creatinine 6.5 mg/dl 4. Uric acid analysis 3.5 mg/dl and phenolsulfonphthalein (PSP) excretion 75%

3 RATIONALES: The normal BUN level ranges 8 to 23 mg/dl; the normal serum creatinine level ranges from 0.7 to 1.5 mg/dl. The test results in option 3 are abnormally elevated, reflecting CRF and the kidneys' decreased ability to remove nonprotein nitrogen waste from the blood. CRF causes decreased pH and increased hydrogen ions — not vice versa. CRF also increases serum levels of potassium, magnesium, and phosphorous, and decreases serum levels of calcium. A uric acid analysis of 3.5 mg/dl falls within the normal range of 2.7 to 7.7 mg/dl; PSP excretion of 75% also falls within the normal range of 60% to 75%. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client is scheduled for a renal arteriogram. When the nurse checks the chart for allergies to shellfish or iodine, the nurse finds no allergies recorded. The client is unable to provide the information. During the procedure, the nurse should be alert for which finding that may indicate an allergic reaction to the dye used during the arteriogram. 1. Increased alertness 2. Hypoventilation 3. Pruritus 4. Unusually smooth skin

3 RATIONALES: The nurse should be alert for urticaria and pruritus, which may indicate a mild anaphylactic reaction to the arteriogram dye. Decreased (not increased) alertness may occur as well as dyspnea (not hypoventilation). Unusually smooth skin isn't a sign of anaphylaxis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

A 75-year-old client undergoes total hip replacement. After surgery, the client questions why she must go to a rehabilitation center because she has family who can care for her. Which response by the nurse is best? 1. You'll need help with your bath and meals for quite some time." 2. "The rehabilitation staff can provide you with better care." 3. "The rehabilitation staff can evaluate your progress and make sure that you exercise without risking injury." 4. "The doctor wants you to go to the rehabilitation center until you're fully recovered and able to care for yourself."

3 RATIONALES: The nurse should respond by emphasizing that the rehabilitation center can evaluate progress and make sure that exercises are performed without risking injury. This response points out that the goal of rehabilitation is safely achieving mobility, not providing total care. Option 1 doesn't provide adequate information about the role of rehabilitation or the client's future needs. The rehabilitation center will help the client learn to bathe herself. Option 2 is judgmental about care the family might provide and doesn't adequately explain the role of a rehabilitation center. Option 4 doesn't explain the importance of a rehabilitation center. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care COGNITIVE LEVEL: Analysis

A client develops decreased renal function and requires a change in antibiotic dosage. On which factor would the physician base the dosage change? 1. GI absorption rate 2. Therapeutic index 3. Creatinine clearance 4. Liver function studies

3 RATIONALES: The physician orders tests for creatinine clearance to gauge the kidney's glomerular filtration rate; this is important because most drugs are excreted at least partially by the kidneys. The GI absorption rate, therapeutic index, and liver function studies don't help determine dosage change in a client with decreased renal function. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential COGNITIVE LEVEL: Application

The nurse is caring for a male client with gonorrhea who's receiving ceftriaxone and doxycycline. The client asks the nurse why he's receiving two antibiotics. How should the nurse respond? 1. "Because there are many resistant strains of gonorrhea, more than one antibiotic may be required for successful treatment." 2. "The combination of these two antibiotics reduces the risk of reinfection." 3. "Many people infected with gonorrhea are infected with chlamydia as well." 4. "This combination of medications will eradicate the infection faster than a single antibiotic."

3 RATIONALES: Treatment for gonorrhea includes the antibiotic ceftriaxone. Because many people with gonorrhea have a coexisting chlamydial infection, doxycycline or azithromycin is prescribed as well. There has been an increase in the number of resistant strains of gonorrhea, but that isn't the reason for this dual therapy. This combination of antibiotics doesn't reduce the risk of reinfection or provide a faster cure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Comprehension

The nurse is planning a group teaching session on the topic of urinary tract infection (UTI) prevention. Which point would the nurse want to include? 1. Limit fluid intake to reduce the need to urinate. 2. Take medication prescribed for a UTI until the symptoms subside. 3. Notify the physician if urinary urgency, burning, frequency, or difficulty occurs. 4. Wear only nylon underwear to reduce the chance of irritation.

3 RATIONALES: Urgency, burning, frequency, and difficulty urinating are all common symptoms of a UTI. The client should notify his physician so that a microscopic urinalysis can be done and appropriate treatment can be initiated. The client should be instructed to drink 2 to 3 L of fluid per day to dilute the urine and reduce irritation of the bladder mucosa. The full amount of antibiotics prescribed for UTIs must be taken despite the fact that the symptoms may have subsided. This will help to prevent recurrences of UTI. Women are told to avoid scented toilet tissue and bubble baths and to wear cotton underwear, not nylon, to reduce the chance of irritation. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

The nurse is caring for a client diagnosed with acute renal failure. The nurse notes on the intake and output record that the total urine output for the previous 24 hours was 95 ml. Urine output that's less than 100 ml in 24 hours is known as: 1. oliguria. 2. polyuria. 3. anuria. 4. hematuria.

3 RATIONALES: Urine output less than 100 ml in 24 hours is called anuria. Urine output of less than 400 ml but more than 100 ml in 24 hours is called oliguria. Polyuria is excessive urination. Hematuria is the presence of blood in the urine. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Comprehension

A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hr. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? 1. Blood urea nitrogen (BUN) level of 22 mg/dl 2. Serum creatinine level of 1.2 mg/dl 3. Temperature of 100.2° F (37.8° C) 4. Urine output of 250 ml/24 hours

4 RATIONALES: ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is demonstrated by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. I.V. fluid is being infused at 150 ml/hr. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)? 1. Blood urea nitrogen (BUN) level of 22 mg/dl 2. Serum creatinine level of 1.2 mg/dl 3. Temperature of 100.2° F (37.8° C) 4. Urine output of 250 ml/24 hours Correct Answer: 4 Your Answer

4 RATIONALES: ARF, characterized by abrupt loss of kidney function, commonly causes oliguria, which is demonstrated by a urine output of 250 ml/24 hours. A serum creatinine level of 1.2 mg/dl isn't diagnostic of ARF. A BUN level of 22 mg/dl or a temperature of 100.2° F (37.8° C) wouldn't result from this disorder. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first? 1. Blood pressure 2. Respirations 3. Temperature 4. Pulse

4 RATIONALES: An elevated serum potassium level may lead to a life-threatening cardiac arrhythmia, which the nurse can detect immediately by palpating the pulse. The client's blood pressure may change, but only as a result of the arrhythmia. Therefore, the nurse should assess blood pressure later. The nurse also can delay assessing respirations and temperature because these aren't affected by the serum potassium level. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

During a routine examination, the nurse notes that the client seems unusually anxious. Anxiety can affect the genitourinary system by: 1. slowing the glomerular filtration rate. 2. increasing sodium resorption. 3. decreasing potassium excretion. 4. stimulating or hindering micturition.

4 RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable effect is to cause frequent voiding and urinary urgency. However, when anxiety leads to generalized muscle tension, it may hinder urination because the perineal muscles must relax to complete micturition. Anxiety doesn't slow the glomerular filtration rate, increase sodium resorption, or decrease potassium excretion. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Knowledge

A client requires hemodialysis. Which type of drug should be withheld before this procedure? 1. Phosphate binders 2. Insulin 3. Antibiotics 4. Cardiac glycosides

4 RATIONALES: Cardiac glycosides such as digoxin should be withheld before hemodialysis. Hypokalemia is one of the electrolyte shifts that occur during dialysis, and a hypokalemic client is at risk for arrhythmias secondary to digitalis toxicity. Phosphate binders and insulin can be administered because they aren't removed from the blood by dialysis. Some antibiotics are removed by dialysis and should be administered after the procedure to ensure their therapeutic effects. The nurse should check a formulary to determine whether a particular antibiotic should be administered before or after dialysis. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application

The nurse is teaching a client with genital herpes. Education for this client should include an explanation of: 1. the need for the use of petroleum products. 2. why the disease is transmittable only when visible lesions are present. 3. the option of disregarding safer-sex practices now that he's already infected. 4. the importance of informing his partners of the disease.

4 RATIONALES: Clients with genital herpes should inform their partners of the disease. Petroleum products should be avoided because they can cause the virus to spread. The notion that genital herpes is only transmittable when visible lesions are present is false. Anyone not in a long-term, monogamous relationship, regardless of current health status, should follow safer-sex practices. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None COGNITIVE LEVEL: Application

The nurse is caring for a client with acute renal failure. The nurse should expect that hypertonic glucose, insulin infusions, and sodium bicarbonate will be used to treat what complication of acute renal failure? 1. Hypokalemia 2. Hyperphosphatemia 3. Hypophosphatemia 4. Hyperkalemia

4 RATIONALES: Hyperkalemia is a common complication of acute renal failure. The administration of glucose and regular insulin infusions, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing potassium levels. This treatment isn't used to treat hyperphosphatemia or hypophosphatemia. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application

The client underwent a transurethral resection of the prostate gland 24 hours ago and is on continuous bladder irrigation. Which nursing intervention is appropriate? 1. Tell the client to try to urinate around the catheter to remove blood clots. 2. Restrict fluids to prevent the client's bladder from becoming distended. 3. Prepare to remove the catheter. 4. Use aseptic technique when irrigating the catheter.

4 RATIONALES: If the catheter is blocked by blood clots, it may be irrigated according to physician's orders or facility protocol. The nurse should use sterile technique to reduce the risk of infection. Urinating around the catheter can cause painful bladder spasms. Encourage the client to drink fluids to dilute the urine and maintain urine output. The catheter remains in place for 2 to 4 days after surgery and is only removed with a physician's order. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A 25-year-old female client seeks care for a possible infection. Her symptoms include burning on urination and frequent, urgent voiding of small amounts of urine. She's placed on trimethoprim-sulfamethoxazole (Bactrim) to treat possible infection. Another medication is prescribed to decrease the pain and frequency. Which is the most likely medication prescribed for the pain? 1. nitrofurantoin (Macrodantin) 2. ibuprofen (Motrin) 3. acetaminophen with codeine 4. phenazopyridine (Pyridium)

4 RATIONALES: Phenazopyridine may be prescribed in conjunction with an antibiotic for painful bladder infections to promote comfort. Because of its local anesthetic action on the urinary mucosa, phenazopyridine specifically relieves bladder pain. Nitrofurantoin is a urinary antiseptic with no analgesic properties. Although ibuprofen and acetaminophen with codeine are analgesics, they don't exert a direct effect on the urinary mucosa. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application

The nurse is assessing a male client diagnosed with gonorrhea. Which symptom most likely prompted the client to seek medical attention? 1. Rashes on the palms of the hands and soles of the feet 2. Cauliflower-like warts on the penis 3. Painful red papules on the shaft of the penis 4. Foul-smelling discharge from the penis

4 RATIONALES: Symptoms of gonorrhea in men include purulent, foul-smelling drainage from the penis and painful urination. Rashes on the palms of the hands and soles of the feet are symptoms of the secondary stage of syphilis. Cauliflower-like warts on the penis are a sign of human papillomavirus. Painful red papules on the shaft of the penis may be a sign of the first stage of genital herpes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Application

A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment? 1. Force oral fluids. 2. Administer furosemide (Lasix) 20 mg I.V. 3. Start hemodialysis after a temporary access is obtained. 4. Start I.V. fluids with a normal saline solution bolus followed by a maintenance dose.

4 RATIONALES: The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize. The client wouldn't be able to tolerate oral fluids because of the nausea, vomiting, and diarrhea. The client isn't fluid-overloaded so his urine output won't increase with furosemide, which would actually worsen the client's condition. The client doesn't require dialysis because the oliguria and elevated BUN and creatinine levels are caused by dehydration. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation COGNITIVE LEVEL: Analysis

The physician prescribes a single dose of trimethoprim/sulfamethoxazole (Bactrim) by mouth for a client diagnosed with an uncomplicated urinary tract infection (UTI). The pharmacy sends three unit-dose tablets. The nurse verifies the physician's order. What should the nurse do next? 1. Administer the three tablets as the single dose. 2. Call the physician to verify the order. 3. Give one tablet, three times per day. 4. Call the hospital pharmacist and question the medication supplied.

4 RATIONALES: The nurse should call the hospital pharmacy and question the medication supplied. The hospital pharmacist should be able to tell the nurse whether three tablets are necessary for the single dose or whether a dispensing error occurred. It isn't clear whether the three tablets are the single dose because they were packaged as a unit-dose. The physician order was clearly written, so clarifying the order with the physician isn't necessary. Administering the tablets without clarification might cause a medication error. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies COGNITIVE LEVEL: Application