Medical Surgical Chapter 45 Urinary System

2, 4, 5 Kidney stones, or the formation of renal calculi, may cause hematuria, or blood in the urine. Renal calculi formation may be caused by excessive intake of dairy products, such as milk, butter, and cheese. Therefore, in order to prevent the further formation of kidney stones, the nurse should suggest that the patient limit the intake of dairy products. Eating asparagus may make the urine smell musty, but it does not cause hematuria. Drinking carbonated beverages may help alleviate urinary inflammatory diseases, so these beverages do not need to be limited. Text Reference - p. 1053

The nurse explains dietary modifications to a patient with hematuria and kidney stones. Which statement made by the patient indicates the need for further teaching? Select all that apply. 1 "I should limit my intake of asparagus." 2 "I should drink two glasses of milk every day." 3 "I should limit my intake of carbonated beverages." 4 "I should include cheese in my diet, because it is rich in protein." 5 "I can have two pieces of bread with butter for breakfast and dinner."

2 Ideally, the specimen for urinalysis should be examined within one hour of urinating. If immediate analysis is not possible, the urine sample should be refrigerated. If the urine sample is not refrigerated, bacteria will start multiplying. The red blood cells tend to hemolyze, casts disintegrate, and the urine becomes alkaline as a result of urea-splitting bacteria. There is no reason for the specimen to be discarded. Storing the specimen at 25o C would still likely cause bacteria to multiply. Text Reference - p. 1056

The nurse in a primary health care facility has collected a urine specimen from a patient for a urinalysis. The lab where the specimen is to be examined is two hours away from the facility. What is the most appropriate action by the nurse? 1 Discard the urine specimen. 2 Refrigerate the urine specimen. 3 Send the specimen to the lab immediately. 4 Store the specimen at 25o C.

2 A clean catch midstream urine sample is ideal for obtaining a urine culture because it is the method that is least likely to be contaminated. However, if the patient cleans the meatus in a back-to-front motion, the urine may get contaminated with microorganisms from the anal area. Therefore, the patient should be instructed to clean the meatus in a front-to-back motion. The urine sample should be collected in a sterile specimen container for accurate culture results. The patient should use at least three sponges saturated with a cleansing solution to clean the meatus because this helps to prevent contamination of the urine sample. After the cleaning, the patient starts voiding, and then continues voiding into the sample container. This midstream collection helps to ensure that the sample is without any contaminants. Text Reference - p. 1057

The nurse instructs a female patient to collect a clean catch midstream urine sample for a culture. Which patient action may contaminate the urine sample? 1 The patient collects the urine sample in a sterile specimen cup. 2 The patient cleans the urinary meatus in a back-to-front motion. 3 The patient uses three sponges saturated with cleansing solution for cleaning. 4 The patient starts urinating and then continues urinating in the sample container.

1, 2, 5 Hematuria is the presence of blood in the urine. Renal calculi or kidney stones are a potential cause of blood in the urine. As the stones grow, they may irritate the lining of the kidney and the ureter and injure the cells and capillaries, resulting in hematuria. Blood dyscrasias is a condition in which the constituents of the blood are abnormal, which can lead to hematuria. Cancer of the genitourinary tract is also a major cause of hematuria. The nurse anticipates diabetes mellitus if the patient has glycosuria. The nurse anticipates severe dehydration if the patient's urine contains proteins. Text Reference - p. 1056

The nurse is assessing a patient with hematuria. What possible causes does the nurse anticipate for this condition? Select all that apply. 1 Renal calculi 2 Blood dyscrasias 3 Diabetes mellitus 4 Severe dehydration 5 Genitourinary tract cancer

2, 3, 4 A severely dehydrated patient has altered blood flow to the kidneys, leading to acute kidney injury. If the patient is severely dehydrated, proteins are excreted in the urine. Dehydration increases specific gravity of the urine due to loss of fluids. Dehydration decreases urine output and frequency but does not cause polyuria. Dehydration causes an increase, not a decrease, in the BUN/creatinine ratio. Text Reference - p. 1053

The nurse is assessing a severely dehydrated patient who has urinary problems. Which findings does the nurse anticipate seeing in the patient's laboratory report? Select all that apply. 1 Polyuria 2 Acute kidney injury 3 Persistent proteinuria 4 Increase in specific gravity 5 Decrease in BUN/creatinine ratio

2 A renal biopsy may cause flank plain, an increase in body temperature, and internal bleeding. Therefore, to ensure safety the nurse should monitor the vital parameters frequently and perform the urine dipstick test to detect presence of blood in the urine. The nurse also ensures that the patient lies on the affected side for 30 to 60 minutes after the procedure. Asking the patient to lie in a side-lying position cannot prevent infection and urinary retention. Renal biopsy does not involve use of contrast media; therefore, hypersensitivity reaction might not occur. Text Reference - p. 1061

The nurse is caring for a patient who has undergone a renal biopsy. The nurse ensures that the patient lies on the affected area for 30 to 60 minutes, conducts urine serial urine tests using a dipstick, and measures the vital parameters frequently. The nurse performs the interventions to assess for and prevent which complication? 1 Infection 2 Bleeding 3 Urinary retention 4 Hypersensitivity

2 Urine cytological studies help to identify abnormal cellular structures, characteristic features of bladder cancer. Because epithelial cells held in the bladder overnight may undergo changes and interfere with results, the first-voided urine of the day should not be collected as a sample for this test. The nurse should immediately send the specimen to the lab after receiving the specimen. This prevents contamination from urine sitting for too long. The patient should be instructed to clean the urinary meatus prior to obtaining the sample. The nurse should also instruct the patient to urinate in the toilet first, then in the cup. This prevents urethral and labial contaminants in the specimen. Text Reference - p. 1057

The nurse is caring for a patient who is suspected to have bladder cancer. A urine cytological study has been prescribed. Which action during the study may interfere with the test results? 1 The nurse sends the urine sample to the lab immediately after collection. 2 The patient provides the first voided urine sample of the day. 3 The patient cleans the meatus before obtaining the urine sample. 4 The nurse instructs the patient to urinate in the toilet first, then the specimen cup.

4 There should be no odor present in urine. If one is detected, the patient may have a urinary tract infection. In a normal urine sample, there should not be any glucose present. If there is glucose present in the urine, the patient may have uncontrolled diabetes mellitus. RBCs are not present in a normal urine sample, because this might indicate renal calculi. An individual can have a trace amount of protein in the urine and that is normal. If there is more protein present, the patient may have chronic kidney disease. Text Reference - p. 1062

The nurse is reviewing the urinalysis report of a patient. What does the nurse infer from the patient's report? 1 The patient has renal calculi. 2 The patient has diabetes mellitus. 3 The patient has chronic kidney disease. 4 The patient has a urinary tract infection.

3 A tight feeling in the throat indicates the possible development of a severe allergic reaction to the dye used during intravenous pyelography, resulting in edema of the larynx and difficulty breathing. Flushing of the face, a salty taste in the mouth, and a feeling of warmth over the body are all possible and expected side effects during this procedure. They are usually transient and nondistressing. Text Reference - p. 1058

The nurse observes a patient who is undergoing an intravenous pyelogram. Which patient reaction during the procedure should the nurse report to the primary health care provider immediately? 1 Flushing of the face 2 Salty taste in the mouth 3 Tight sensation in the throat 4 Feeling of warmth over the entire body

4 Urine output of 100 to 400 mL within 24 hours indicates severe dehydration. As body fluids decrease in the body, the kidneys will not be able to eliminate fluids from the body. Urethritis is an infection in the urinary tract and may cause pain in the patient. Heart failure may lead nocturia in the patient. Urethral irritation may cause burning upon urination. Text Reference - p. 1056

The nurse reviews a patient's medical record and notes that the urine output for the previous 24 hours is 200 mL. The nurse concludes that the likely reason for this output is the patient's history of what? 1 Urethritis 2 Heart failure 3 Urethral irritation 4 Severe dehydration

4 The kidneys perform vital functions through participation in red blood cell (RBC) production and blood pressure regulation. Erythropoietin is a hormone produced in the kidneys and secreted in response to hypoxia and decreased renal blood flow. Erythropoietin stimulates RBC production in the bone marrow. A deficiency of erythropoietin occurs in kidney failure, leading to anemia. The patient with kidney failure (also called renal failure) has a deficiency of the active metabolite of vitamin D and manifests problems of altered calcium and phosphate balance. Renin is released into the bloodstream in response to decreased renal perfusion, decreased arterial blood pressure, decreased extracellular fluid (ECF), decreased serum Na+concentration, and increased urinary Na+concentration. It has no direct effect on blood cell production. Text Reference - p. 1049

The patient developed progressive renal failure 10 years ago and has been on dialysis for the last five years. The patient also has developed chronic anemia. There are many causes of anemia, but the most likely cause of anemia in this patient would be 1 Increased vitamin D production 2 Decreased renin production 3 Increased erythropoietin production 4 Decreased erythropoietin production

4 Together, the bladder, urethra, and pelvic floor muscles form what is called the urethrovesical unit. Voluntary control of this unit is defined as continence. Stimulating and inhibiting impulses are sent from the brain through the thoracolumbar (T11 to L2) and sacral (S2 to S4) areas of the spinal cord to control voiding. Damage in this area will prevent voluntary control and lead to incontinence. Without control, the patient may not be aware of the need to go to the bathroom, to use a urinal/bedpan, or to call for assistance. Text Reference - p. 1054

The patient is admitted to the hospital following a motor vehicle crash in which the patient sustained severe spinal cord injury in the sacral and thoracolumbar regions. The nurse anticipates that the patient will: 1 Be able to ambulate to the bathroom 2 Need to use a urinal/bedpan to urinate 3 Call for assistance when he or she needs to void 4 Most likely be incontinent

2 The result of a creatinine clearance test closely approximates that of the GFR. Creatinine levels remain remarkably constant for each person because they are not significantly affected by protein ingestion, muscular exercise, water intake, or rate of urine production. After age 40, the creatinine clearance rate decreases at a rate of about 1 mL/min/yr. Normal creatinine clearance values range from 70 to 135 mL/min. Text Reference - p. 1061

The patient is undergoing a 24-hour urine collection for creatinine clearance. During collection of the specimen, what does the nurse consider? 1 Creatine levels vary greatly among individuals 2 The creatinine clearance closely approximates glomerular filtration rate (GFR) 3 Creatinine levels are not affected by age 4 Creatinine levels are affected significantly by protein ingestion

1, 4, 5 Ketones in the urine may indicate that the patient is starving. During fasting, the metabolism of carbohydrate and fat increases, which increases ketone levels in the urine. Severe diarrhea is associated with metabolic acidosis and results in the excretion of ketones in the urine. Altered carbohydrate metabolism also leads to ketones in the urine. Red blood cells in the patient's urine may be a sign of tuberculosis. Bilirubin is present in the urine sample of a patient who has a liver disorder. Text Reference - p. 1062

The urinalysis reports of a patient indicate the presence of ketones in the patient's urine. What conditions could this finding indicate? Select all that apply. 1 The patient is starving. 2 The patient has tuberculosis. 3 The patient has liver disorder. 4 The patient has severe diarrhea. 5 The patient's carbohydrate metabolism is altered.

1 Although a specimen may be collected at any time of the day for a routine urinalysis, it is best to obtain the first specimen urinated in the morning. This concentrated specimen is more likely to contain abnormal constituents if they are present in the urine. The specimen should be examined within one hour of urinating. It is not necessary to collect the urine overnight. Text Reference - p. 1061

What advice should the nurse give to the patient collecting a urine sample for urinalysis? 1 Collect the first urine sample in the morning. 2 Collect the urine sample at any time during the day. 3 Collect the urine overnight. 4 Take the sample collected one hour after voiding a first sample.

4, 5 A normal RBC count in the urine is less than 4/hpf and a normal WBC count in the urine is less than 5/hpf. Therefore, a patient with a urinary tract infection (UTI) would present with a WBC count greater than 5/hpf. As renal calculi move through the urinary tract, they cause injury to the structures. This would cause RBCs to be found in the urine. If the RBC count is greater than 5/hpf, it may be indicative of renal calculi in the patient. A urine specific gravity of 0.9 indicates excessive dieresis and very dilute urine. This is because lower specific gravity than the range of 1.003 to 1.030 indicates dieresis. In a patient with a UTI, the bacteria count in urine is greater than 104 organisms/mL. Protein should be absent or found in trace amounts in the urine. Excess protein can be found in patients with glomerular membrane damage. Text Reference - p. 1062

What findings should the nurse expect in the urinalysis report of a patient with a urinary tract infection and renal calculi? Select all that apply. 1 Specific gravity of 0.9 2 Bacteria count of 103 organisms/mL 3 Protein concentration of 100 mg/day 4 Red blood cell (RBC) concentration of 5/hpf 5 White blood cell (WBC) concentration of 7/hpf

4 The ureterovesical junction (UVJ) is the narrowest part of the urethra and easily obstructed by urinary calculi. With a stone in the kidney or at the UPJ, the pain may be dull costovertebral flank pain. Stones in the bladder do not cause obstruction or symptoms unless they are staghorn stones. The urethra seldom has obstruction related to stones. Text Reference - p. 1049

When the patient reports acute, severe, renal colic pain in the lower abdomen, the nurse knows that the patient is most likely to have an obstruction at which area? 1 Kidney 2 Urethra 3 Bladder 4 Ureterovesical junction

1, 5 Castor oil and bisacodyl are the bowel preparations suitable for a patient with kidney failure, because these preparations can easily be eliminated by the patient. Fleet enema, Milk of Magnesia, and magnesium citrate are not suitable bowel preparations for this patient, because they contain magnesium, which cannot be eliminated by a patient with kidney failure. Text Reference - p. 1055

Which bowel preparations are appropriate for a patient with kidney failure? Select all that apply. 1 Castor oil 2 Fleet enema 3 Milk of Magnesia 4 Magnesium citrate 5 Bisacodyl

3 Bumetanide is a loop diuretic that acts in the loop of Henle to decrease reabsorption of sodium and chloride. Because the loop of Henle loses function with aging, the excretion of drugs becomes less and less efficient. Thus the circulating levels of drugs are increased and their effects prolonged. The benign enlargement of prostatic tissue, decreased sensation of bladder capacity, and loss of concentrating ability do not affect directly the action of loop diuretics. Text Reference - p. 1052

Which effect of aging on the urinary system is most likely to affect the action of bumetanide? 1 Benign enlargement of prostatic tissues 2 Decreased sensation of bladder capacity 3 Decreased function of the loop of Henle 4 Less absorption in the Bowman's capsule

2, 3, 4 For radiologic studies of the urinary system such as an intravenous pyelogram, bowel preparation is important. Because the kidneys lie in a retroperitoneal location, the contents of the colon may obstruct visualization of the urinary tract. If the bowel preparation fails to adequately evacuate the lower tract, the study may be unsuccessful and have to be rescheduled. Commonly used bowel preparations include enemas, castor oil, magnesium citrate, and bisacodyl tablets or suppositories. However, some bowel preparations, including magnesium citrate and Fleet enema, are contraindicated because magnesium cannot be excreted by the kidneys in patients with kidney failure. Text Reference - p. 1055

Which forms of bowel preparations are used in patients undergoing an intravenous pyelogram? Select all that apply. 1 Fleet enema 2 Castor oil 3 Bisacodyl tablets 4 Bisacodyl suppositories 5 Bowel preparation not required

4 Normal WBC levels in urine are below 5/hpf, with levels exceeding this indicative of inflammation or urinary tract infection. A urine pH of 6.0 is average, amber yellow is normal coloration, and the reference ranges for specific gravity are 1.003 to 1.030. Text Reference - p. 1061

Which urinalysis result should the nurse recognize as an abnormal finding? 1 pH 6.0 2 Amber yellow color 3 Specific gravity 1.025 4 White blood cells (WBCs) 9/hpf

1 Nursing responsibilities in caring for a patient undergoing an IVP include administration of a cathartic or enema to empty the colon of feces and gas. The nurse also will assess the patient for iodine sensitivity, keep the patient NPO for eight hours preprocedure, and advise the patient that warmth, a flushed face, and a salty taste during injection of contrast material may occur. Text Reference - p. 1058

A patient is scheduled for an intravenous pyelogram (IVP). What is the priority action by the nurse to prepare the client for the procedure? 1 Administer a cathartic or enema. 2 Assess patient for allergies to penicillin. 3 Keep the patient nothing by mouth (NPO) for four hours preprocedure. 4 Advise the patient that a metallic taste may occur during procedure.

1 Pink-tinged urine, burning, and frequency are common following a cystoscopy. The patient does not need to be nothing by mouth before the test and contrast media is not needed. A cystoscopy does not always necessitate catheterization before or after the procedure. Text Reference - p. 1059

A patient with a history of recurrent urinary tract infections has been scheduled for a cystoscopy. What teaching point should the nurse emphasize before the procedure? 1 "You might have pink-tinged urine and burning after your cystoscopy." 2 "You'll need to refrain from eating or drinking after midnight the day before the test." 3 "You'll require a urinary catheter inserted before the cystoscopy and it will be in place for a few days." 4 "The morning of the test, the nurse will ask you to drink some water that contains a contrast solution."

4 Erythropoietin is a hormone produced by the kidneys that promotes red blood cell (RBC) production in the bone marrow. In kidney failure, the kidneys are unable to produce erythropoietin, resulting in a decreased production of RBCs and anemia. Patients with kidney failure may have renal hypertension; however, renal hypertension does not cause anemia. Patients with kidney failure have altered bone metabolism due to a lack of vitamin D, active metabolite, and tubule dysfunction. However, altered bone metabolism does not result in anemia. Excessive renin production in kidney failure causes hypertension but is unrelated to anemia. Text Reference - p. 1049

A patient with chronic kidney failure has a hemoglobin (Hb) level of 8.0 g/dL. What should the nurse infer about the reason for this laboratory result? 1 The patient has renal hypertension. 2 The patient has altered bone metabolism. 3 The patient has excessive renin production. 4 The patient has a deficiency of erythropoietin.

3 Aldosterone (released from the adrenal cortex) acts on the distal tubule to cause reabsorption of Na+ and water. In exchange for Na+, potassium ions (K+) are excreted. The secretion of aldosterone is influenced by both circulating blood volume and plasma concentrations of Na+ and K+. Text Reference - p. 1048

Aldosterone acts on the distal tubule of the kidney to: 1 Cause the excretion of sodium 2 Cause the excretion of water 3 Cause the excretion of potassium 4 Exchange sodium for water.

4 Because almost all creatinine in the blood is excreted normally by the kidneys, creatinine clearance is the most accurate indicator of renal function. It is a commonly used test to analyze renal function and urinary system disorders. The result of a creatinine clearance test closely approximates that of the glomerular filtration rate. Urinalysis is a general examination of urine to establish baseline information. Composite urine collection measures specific components, such as electrolytes, glucose, protein, 17-ketosteroids, catecholamines, creatinine, and minerals. BUN is used to detect renal problems, but is not as reliable as creatinine clearance. Text Reference - p. 1061

Because almost all creatinine in the blood is excreted normally by the kidneys, which is the most accurate indicator of renal function? 1 Urinalysis 2 Composite urine collection 3 Blood urea nitrogen (BUN) 4 Creatinine clearance

3 The costovertebral angle (CVA) is the landmark to locate the kidneys. It is formed by the rib cage and the vertebral column. Pain and CVA tenderness may indicate a kidney infection or polycystic kidney disease. Kidneys are posterior organs and may not be palpated anteriorly, either below the rib cage or near the umbilicus. The angle formed by the first rib and the vertebral column is too high, as the kidneys are located at a lower position in the abdomen. Text Reference - p. 1054

During the physical assessment of a patient, where should a nurse palpate to locate the kidneys? 1 Anteriorly on the abdomen below the rib cage 2 Anteriorly on the abdomen near the umbilicus 3 In the angle formed by the rib cage and the vertebral column 4 In the angle formed by the first rib and the vertebral column

2 Atrial natriuretic peptide (ANP) inhibits renin, aldosterone, and angiotensin II, preventing reabsorption of sodium and water. Therefore, if a drug inhibits ANP, the enhanced action of renin, aldosterone, and angiotensin II would accelerate reabsorption of sodium and water from urine, which would result in highly concentrated urine. The presence of ANP inhibits renin, aldosterone, and angiotensin II, facilitating production of diluted urine in large volumes. Inhibition of ANP would not result in normal urine volume, because the action of renin, aldosterone, and angiotensin II is enhanced. Text Reference - p. 1048

The nurse administers a drug that inhibits atrial natriuretic peptide (ANP) to a patient. The nurse expects what effects of the medication? 1 The urine will be diluted. 2 The urine will be concentrated. 3 The urine output will increase. 4 The urine concentration and output will be unaffected

2 After procedure: Apply pressure dressing and keep patient on affected side for 30 to 60 minutes. Bedrest for 24 hours. Vital signs every 5 to 10 minutes the first hour. Assess for flank pain, hypotension, decreasing hematocrit, elevated temperature, chills, urinary frequency, dysuria, and serial urine specimens (gross or microscopic hematuria). Urine dipstick can be used to test for bleeding in urine. Inspect biopsy site for bleeding. Instruct patient to avoid lifting heavy objects for five to seven days and to not take anticoagulant drugs until allowed by the health care provider. Text Reference - p. 1061

The patient has undergone renal biopsy. After the procedure the nurse should: 1 Apply pressure dressing and lay the patient on the unaffected side 2 Obtain serial urine specimens and assess the patient's hematocrit 3 Restart patient's aspirin as soon as possible 4 Ambulate the patient after 60 minutes

1 Presence of an excess amount of bilirubin in the urine causes an olive green discoloration of the urine. Jaundice is associated with an increase in bilirubin levels, so the patient should be tested for liver disorders. Dark or smoke-colored urine is a sign of hematuria caused by the presence of red blood cells (RBCs); therefore, this patient does not need to have kidney testing. The nurse would test the lungs for signs of tuberculosis if mycobacteriaceae were found in the urine. Elevated glucose levels in the blood would be an indication of diabetes and would indicate the need for pancreas testing, but that does not apply to this patient. Text Reference - p. 1062

While collecting the urine sample of a patient, the nurse finds that the patient's urine is olive green-colored and has an unpleasant odor. Which organ system should be further tested? 1 Liver 2 Lungs 3 Kidneys 4 Pancreas