Med-Surg Chapter 69

A client has been admitted from a nursing home for a workup to determine the cause of several recent falls. What intervention by the nurse takes priority? a. Obtain a clean catch or catheterized urine specimen. b. Document the number of and causative factors for falls. c. Review the results of recent laboratory work for kidney function. d. Facilitate neurologic and social work consultations.

A Although all interventions are or might be important, obtaining a urine sample for urinalysis takes priority. Often UTI symptoms in older adults are atypical, and a UTI may present with new onset of confusion or of falling.

Which type of incontinence is most common after a difficult vaginal delivery? a. Stress b. Urge c. Reflex d. Overflow

A Childbirth is most likely to result in stress incontinence. No evidence indicates that childbirth is likely to result in the development of urge, reflex, or overflow incontinence.

A client has a history of renal calculi. Which statement by the client indicates a good understanding of preventive measures? a. "I know I should drink at least 3 to 4 liters of fluid every day." b. "I can't eat much dairy or other sources of calcium." c. "Aspirin and aspirin-containing products can lead to stones." d. "The doctor will give me antibiotics at the first sign of a stone."

A Dehydration contributes to the precipitation of minerals to form a stone. Ingestion of calcium or aspirin does not cause a stone. Antibiotics neither prevent nor treat a stone.

Which client is at greatest risk for development of a bacterial cystitis? a. Older woman not taking estrogen replacement b. Older man with mild congestive heart failure c. Middle-aged woman who has never been pregnant d. Middle-aged man taking cyclophosphamide for cancer therapy

A Females at any age are more susceptible to cystitis than men because of the shorter urethra in women. Postmenopausal women who are not on hormone replacement therapy are at increased risk for bacterial cystitis because of changes in the cells of the urethra and vagina. The middle-aged woman who has never been pregnant would not have a risk potential as high as the older woman who is using hormone replacement therapy.

The nurse is working in an incontinence clinic and sees older clients. The nurse plans a habit training program for the client with which condition? a. Confusion b. Diabetes c. Early kidney failure d. Arthritis

A For a bladder training program to succeed in urge incontinence, the client must be alert, aware, and able to resist the urge to urinate. Habit training will work best for a confused client. This includes going to the bathroom (or being assisted to the bathroom) at set times.

Which statement made by a client with stress incontinence indicates a need for clarification of nutrition therapy? a. "I will limit my total intake of fluids." b. "I will avoid drinking alcoholic beverages." c. "I will avoid drinking caffeinated beverages." d. "I will try to lose about 10% of my body weight."

A Limiting fluids concentrates urine and can irritate tissues, leading to increased incontinence. Many people try to manage incontinence by limiting fluids. Alcoholic and caffeinated beverages are bladder stimulants. Obesity increases intra-abdominal pressure, causing incontinence.

A client is being admitted with a suspected diagnosis of bladder cancer. Which question assists the nurse in determining risk factors? a. "Do you smoke cigarettes?" b. "Do you use alcohol?" c. "Do you use recreational drugs?" d. "Do you take any prescription drugs?"

A Smoking is known to be a factor that greatly increases the risk of bladder cancer. Alcohol use, prescription drug use (except medications that contain phenacetin), and recreational drug use are not known to increase the risk of developing bladder cancer.

A young woman is being treated with amoxicillin (Amoxil) for a urinary tract infection. Which is the highest priority instruction for the nurse to give this client? a. "Use a second form of birth control while on the drug." b. "You will experience increased menstrual bleeding while on this drug." c. "You may experience an irregular heartbeat while on the drug." d. "Watch for blood in your urine while taking this drug."

A The client should use a second form of birth control because penicillin seems to reduce the effectiveness of estrogen-containing contraceptives. She should not experience increased menstrual bleeding, an irregular heartbeat, or blood in her urine while taking the medication.

A client is hospitalized with urinary retention, has an indwelling catheter, and is getting IV fluids. Which intervention does the nurse add to the care plan to address the priority problem for this client? a. Perform catheter care per policy every shift. b. Encourage fluid intake to 1 liter/day. c. Apply a moisture barrier cream daily. d. Document accurate intake and output (I&O) each shift.

A The most common cause of sepsis in hospitalized clients is a urinary tract infection. Ascending infection from cystitis with an indwelling catheter is a major source of such infections. Encouraging fluids and documenting I&O are probably important interventions, but they do not take priority over preventing a catheter-related infection. Moisture barrier cream would not be needed.

A client has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. "How much water do you drink every day?" b. "Do you take estrogen replacement?" c. "Does anyone in your family have a history of cystitis?" d. "Do you have any condition that affects your immune system?" e. "Are you on steroids or other immune suppressant drugs?" f. "Do you drink grapefruit juice every day?"

A, B, D, E

The nurse is teaching a client about self-catheterization in the home setting. Which instructions are applicable? (Select all that apply.) a. "Wash your hands before and after self-catheterization." b. "Use a large-lumen catheter for each catheterization." c. "Use lubricant on the tip of the catheter before insertion." d. "Self-catheterize every 12 hours." e. "Use sterile gloves for the procedure." f. "Maintain a specific schedule for catheterization."

A, C, F

The nurse is assessing the laboratory findings of a client with a urinary tract infection. The laboratory report notes a "shift to the left" in a client's white blood cell count. Which action by the nurse is most appropriate? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the health care provider and start an IV line for parenteral antibiotics. c. Instruct the client to begin straining all urine for renal calculi. d. Document the finding in the client's chart and continue to monitor.

B A left shift most commonly occurs with urosepsis and is seen rarely with uncomplicated urinary tract infections. The nurse will be administering antibiotics, most likely via IV, so he or she should notify the provider and prepare to give the antibiotics. The shift to the left is part of a differential white blood cell count. The client would not need to strain urine for stones, and because sepsis carries a high mortality rate, the nurse should not just note the findings as the only action.

Which client statement indicates a good understanding regarding antibiotic therapy for recurrent urinary tract infections? a. "If my urine becomes lighter and clearer, I can stop taking my medicine." b. "Even if I feel completely well, I should take the medication until it is gone." c. "When my urine no longer burns, I will no longer need to take the antibiotics." d. "If I have a fever higher than 100° F (37.8° C), I should take twice as much medicine."

B Antibiotic therapy is most effective, especially for recurrent urinary tract infections, when the client takes the prescribed medication for the entire course, not just when symptoms are present. The other statements demonstrate that additional teaching is needed for the client.

A client has a fungal urinary tract infection. Which assessment by the nurse is most helpful? a. Palpating and percussing the kidneys and bladder b. Assessing medical history and current medical problems c. Performing a bladder scan to assess post-void residual d. Inquiring about recent travel to foreign countries

B Clients who are severely immune compromised or who have diabetes mellitus are more prone to fungal urinary tract infection. The nurse should assess for these factors. A physical examination and a post-void residual may be needed, but not until further information is obtained. Travel to foreign countries probably would not be as important, because even if exposed, the client needs some degree of immune compromise to develop a fungal urinary tract infection.

A client presents with senile dementia, Alzheimer's type (SDAT), and incontinence. Which therapy will best help this client? a. Bladder training b. Habit training c. Exercise therapy d. Electrical stimulation

B Habit training is the type of bladder training that will be most effective with cognitively impaired clients. Bladder training can be used only with a client who is alert, aware, and able to resist the urge to urinate. Exercise therapy may be too difficult for the cognitively impaired client to grasp, and electrical stimulation will be traumatic for this client.

The nurse is working in a long-term care facility where many clients use habit training to manage incontinence. Which action by unlicensed assistive personnel (UAP) requires intervention by the nurse? a. Toileting clients after meals b. Changing incontinence briefs when wet c. Encouraging clients to drink fluids d. Recording incontinence episodes

B Habit training is undermined by the use of absorbent incontinence briefs or pads. The nurse should re-educate the UAP on the technique of habit training. The other actions by the UAP are appropriate.

A postmenopausal female client has had two episodes of bacterial urethritis in the last 6 months. She asks her nurse why this is happening to her now. Which is the nurse's best response? a. "Your immune system becomes less effective as you age." b. "Low estrogen levels can make the tissue more susceptible to infection." c. "You should be more careful with your personal hygiene in this area." d. "It is likely that you have an untreated sexually transmitted infection."

B Low estrogen levels decrease moisture and the types of secretions in the perineal area and cause other tissue changes, predisposing it to the development of infection. Urethritis is most common in postmenopausal women for this reason. Although immune function does decrease with aging and sexually transmitted diseases (STDs) are a known cause of urethritis, the most likely reason in this client is low estrogen levels. Personal hygiene usually does not contribute to this disease process.

A client in the emergency department reports extreme dry mouth, constipation, and an inability to void. The client's history includes incontinence. Which question by the nurse is most important? a. "Are you drinking plenty of water?" b. "Do you take anticholinergic medication?" c. "Have you tried laxatives or enemas?" d. "Has this type of thing ever happened before?"

B Some types of incontinence are treated with anticholinergic medications such as propantheline (Pro-Banthine). Anticholinergic side effects include dry mouth, constipation, and urinary retention. The nurse needs to know whether the client is on this type of medication because the client's symptoms can be a manifestation of a simple side effect or an overdose. The other questions are not as helpful.

A client is receiving treatment with levofloxacin (Levaquin). Which teaching topics does the nurse include in this client's care plan? a. How to assess blood pressure b. How to assess a radial pulse c. How to assess a carotid pulse d. How to assess respirations

B The client should assess his or her own radial pulse at least twice daily because this class of drugs can induce serious cardiac dysrhythmias. Assessment of blood pressure and respirations will not allow the client to detect these cardiac side effects. The easiest place to find a pulse is at the radial site.

A client is beginning to undergo urinary bladder training. Which is an effective instruction to give this client? a. "Use the toilet at the first urge, rather than at specific intervals." b. "Try to consciously hold your urine until the scheduled toileting time." c. "Initially try to use the toilet at least every half-hour for 24 hours." d. "The toileting interval can be increased once you have been continent for 1 week."

B The client should try to hold the urine consciously until the next scheduled toileting time. Toileting should occur at specific intervals during the training. The toileting interval should be no less than every hour. The interval can be increased once the client becomes comfortable with the interval.

Which personal factor places a client at risk for bladder cancer? a. Working in a lumber yard for 10 years b. 50-pack-year cigarette smoking history c. Numerous episodes of bacterial cystitis d. History of sexually transmitted diseases

B The greatest risk factor for bladder cancer is a long history of tobacco use. The other factors would not necessarily contribute to the development of this specific type of cancer.

A client with a renal calculus has just returned from an extracorporeal shock wave lithotripsy procedure, and the nurse finds an ecchymotic area on the client's right lower back. Which is the nurse's priority intervention? a. Notify the health care provider. b. Apply ice to the site. c. Place the client in the prone position. d. Document the observation in the chart.

B The shock waves can cause bleeding into the tissues through which the waves pass. Application of ice can reduce the extent and discomfort of the bruising.

Which statements about urge incontinence and stress incontinence are true? (Select all that apply.) a. Urge incontinence involves a post-voiding residual volume less than 50 mL. b. Stress incontinence occurs because of weak pelvic floor muscles. c. Stress incontinence usually occurs in people with dementia. d. Urge incontinence can be managed by increasing fluid intake. e. Urge incontinence occurs because of abnormal bladder contractions.

B, E

A client with bladder cancer has undergone a complete cystectomy with ileal conduit. Four hours after the surgery, the nurse observes the stoma to be cyanotic. Which is the nurse's priority action? a. Reassess in 2 hours. b. Loosen the dressing. c. Notify the surgeon. d. Apply oxygen.

C A pale or cyanotic stoma indicates impaired circulation to the stoma and must be treated to prevent necrosis.

A confused client is hospitalized for possible pneumonia and is admitted from the emergency department with an indwelling catheter in place. During interdisciplinary rounds the following day, what question by the nurse takes priority? a. "Do you want daily weights on this client?" b. "Will the client be able to return home?" c. "Can we discontinue the in-dwelling catheter?" d. "Should we get another chest x-ray today?"

C An in-dwelling catheter dramatically increases the risks of urinary tract infection and urosepsis. Nursing staff should ensure that catheters are left in place only as long as they are medically needed. The nurse should inquire about removing the catheter. All other questions might be appropriate, but because of client safety, this question takes priority.

A client with bladder cancer is scheduled to have intravesical chemotherapy. Which statement made by the client indicates correct understanding of this therapy? a. "My hair will start growing back in 3 to 6 weeks after chemotherapy is over." b. "My white blood cell count will drop and I will be at increased risk for infection." c. "This type of chemotherapy is used when no distant metastases are present." d. "Chemotherapy only controls cancer, so I will also need radiation."

C Intravesical chemotherapy is used when the tumor has not metastasized. Once metastasis has occurred, systemic chemotherapy and radiation may be used after surgery. The other statements are not accurate.

A client is receiving acetohydroxamic acid (Lithostat). Which statement by the client indicates a good understanding of this therapy? a. "I should finish this antibiotic even if I am feeling better." b. "I need to drink a full glass of water when I take this drug." c. "My blood will be drawn occasionally for kidney function tests." d. "This medication may turn my urine bright orange and stain my clothes."

C Lithostat is used as long-term therapy with clients who have struvite stones. Lithostat prevents bacteria from splitting urea. Clients receiving Lithostat must have their serum creatinine monitored during therapy. The other statements are not accurate.

A client is receiving treatment with liquid nitrofurantoin (Furadantin). Which is the highest priority instruction that the nurse can provide to this client regarding accurate administration of the medication? a. "The medication should be mixed with cold water before drinking it." b. "Urine will turn orange immediately after you swallow the drug." c. "You should ask the pharmacist for a syringe to measure the dose." d. "The drug is available in granules that must be dissolved."

C Nitrofurantoin is available in a suspension that must be measured accurately for the correct dose. Common household spoons are not accurate for this task, and the client should request a syringe from the pharmacist. The medication does not have to be mixed before taking, and it will not discolor the urine. The drug is not available in granules that are dissolved.

A client with severe bacterial cystitis is prescribed cefadroxil (Duricef) and phenazopyridine (Pyridium). What statement by the client indicates an accurate understanding of these medications? a. "I will not take these drugs with food or milk." b. "I will stop these drugs if I think I am pregnant." c. "An orange color in my urine won't alarm me." d. "I will try to drink a liter of cranberry juice daily."

C Phenazopyridine discolors urine most commonly to a deep reddish orange. Many clients think they have blood in their urine when they see this. In addition, the urine can permanently stain clothing.

A client who has undergone a nephrolithotomy procedure 24 hours ago now has a fever of 101° F (38.3° C). What is the nurse's priority intervention? a. Apply a cooling blanket. b. Strain the client's urine. c. Notify the health care provider. d. Document the finding in the client's chart.

C The elevated temperature indicates a possible infection. Treatment must be initiated as soon as possible to prevent septic complications. The nurse needs to notify the provider so that appropriate diagnostic studies and treatment can be started. The temperature is not high enough to warrant a cooling blanket, and straining the urine will not help find a cause for the fever.

A client has functional urinary incontinence. Which instruction by the nurse to the client and family helps meet an expected outcome for this condition? a. "You must clean around your catheter daily with soap and water." b. "Wash the vaginal weights with a 10% bleach solution after each use." c. "Operations to repair your bladder are available, and you can consider these." d. "Buy slacks with elastic waistbands that are easy to pull down."

D Functional urinary incontinence occurs as the result of problems not related to the client's bladder, such as trouble ambulating or difficulty accessing the toilet. One goal is that the client will be able to manage his or her clothing independently. Elastic waistband slacks that are easy to pull down can help the client get on the toilet in time to void. The other instructions do not relate to functional urinary incontinence.

A client has overflow incontinence. Which intervention does the nurse add to this client's care plan to assist with elimination? a. Stroking the medial aspect of the thigh b. Using intermittent catheterization c. Providing digital anal stimulation d. Using the Valsalva maneuver

D In clients with overflow incontinence, the voiding reflex arc is not intact. Mechanical pressure, such as that achieved through the Valsalva maneuver (holding the breath and bearing down as if to defecate), can initiate voiding.

The caretaker of a confused client with functional incontinence asks about having an in-dwelling catheter placed. Which is the nurse's best response? a. "You must be very aggravated about this situation. I will call the provider with this request." b. "I will teach you how to insert the catheter, which should be used just at night." c. "We can teach you how to perform intermittent catheterization to drain the bladder." d. "Because the client is confused, we need to place priority on keeping the skin clean and dry."

D In-dwelling catheters are used only as a last resort because of the risk for ascending urinary tract infection and sepsis. The use of containment pads should be attempted as a means of controlling wetness first. If the client has skin breakdown, an in-dwelling catheter can be placed temporarily until the area has healed. But for a client with cognitive impairment, continence probably cannot be achieved, so the focus turns to maintaining skin integrity.

Which is an initial priority intervention for a client with stress incontinence? a. Beginning medication and dietary teaching b. Referring the client to an incontinence clinic c. Assisting the client in finding absorbent pads d. Instructing the client to maintain an incontinence diary

D Maintaining a diary detailing times of urine leakage, activities, and foods eaten will aid in the diagnostic process by showing whether a connection can be made between specific factors that seem to trigger the incontinence episodes. Use of medication or absorbent pads or referral to a specialty clinic may be used as part of the treatment plan at some point, but an accurate assessment needs to occur first.

A client has kidney stones from secondary hyperoxaluria. Which medication does the nurse anticipate administering? a. Phenazopyridine (Pyridium) b. Propantheline (Pro-Banthine) c. Tolterodine (Detrol-LA) d. Allopurinol (Zyloprim)

D Stones caused by secondary hyperoxaluria respond to allopurinol (Zyloprim). Pyridium is given to clients with urinary tract infections (UTIs). Pro-Banthine is an anticholinergic. Detrol and Detrol-LA are anticholinergics with smooth muscle relaxant properties.

A client is scheduled to undergo the surgical creation of an ileal conduit. He expresses his anxiety and fear regarding the procedure. Which is an appropriate response from the nurse? a. "Do you think something for your nerves would be helpful?" b. "Would you like to discuss the procedure with your doctor once more?" c. "Are you ready for your sleeping medication now?" d. "Would you like to speak with someone who has an ileal conduit?"

D The goal for the client who is scheduled to undergo a procedure such as an ileal conduit is to have a positive self-image and a positive attitude about his or her body. Medications for anxiety or sleep will not promote this, nor will discussing the procedure once more with the physician. However, discussing the procedure candidly with a former client will foster such feelings, especially when the current client has an opportunity to ask questions and voice concerns to someone with first-hand knowledge of the procedure.