NCLEX - Urinary System Assessment

A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first? a. Assess the clients dietary habits. b. Inquire about the use of nonsteroidal anti-inflammatory drugs (NSAIDs). c. Hold the clients metformin (Glucophage). d. Contact the health care provider immediately.

ANS: A - An elevated BUN/creatinine ratio is often indicative of dehydration, urinary obstruction, catabolism, or a high-protein diet. The nurse should inquire about the clients dietary habits. Kidney damage related to NSAID use most likely would manifest with elevations in both BUN and creatinine, but no change in the ratio. The nurse should obtain more assessment data before holding any medications or contacting the provider.

A client with these assessment data is preparing to undergo a computed tomography (CT) scan with contrast: Flank pain Dysuria Bilateral knee pain BUN 54 mg/dL (19.3 mmol/L) Creatinine 2.4 mg/dL (212 umol/L) Calcium 8.5 mg/dL (2.13 mmol/L) Captopril Metformin Acetylcysteine Which medication does the nurse plan to administer before the procedure? a. Acetylcysteine (Mucomyst) b. Metformin (Glucophage) c. Captopril (Capoten) d. Acetaminophen (Tylenol)

ANS: A - Before a CT scan with contrast, the nurse needs to administer acetylcysteine to the client. This client has kidney impairment demonstrated by increased creatinine. Acetylcysteine (an antioxidant) would be used to prevent contrast-induced nephrotoxic effects.Metformin is held at least 24 hours before and for at least 48 hours after procedures using contrast. Although captopril and acetaminophen may be administered with a sip of water with permission of the provider, this is not essential before the procedure.

A nurse reviews the allergy list of a client who is scheduled for an intravenous urography. Which client allergy should alert the nurse to urgently contact the health care provider? a. Seafood b. Penicillin c. Bee stings d. Red food dye

ANS: A - Clients with seafood allergies often have severe allergic reactions to the standard dyes used during intravenous urography. The other allergies have no impact on the clients safety during an intravenous urography.

A nurse cares for a client with diabetes mellitus who is prescribed metformin (Glucophage) and is scheduled for an intravenous urography. Which action should the nurse take first? a. Contact the provider and recommend discontinuing the metformin. b. Keep the client NPO for at least 6 hours prior to the examination. c. Check the clients capillary artery blood glucose and administer prescribed insulin. d. Administer intravenous fluids to dilute and increase the excretion of dye.

ANS: A - Metformin can cause lactic acidosis and renal impairment as the result of an interaction with the dye. This drug must be discontinued for 48 hours before the procedure and not started again after the procedure until urine output is well established. The clients health care provider needs to provide alternative therapy for the client until the metformin can be resumed. Keeping the client NPO, checking the clients blood glucose, and administering intravenous fluids should be part of the clients plan of care, but are not the priority, as the examination should not occur while the client is still taking metformin.

Which age-related change can cause nocturia? a. Decreased ability to concentrate urine b. Decreased production of antidiuretic hormone c. Increased production of erythropoietin d. Increased secretion of aldosterone

ANS: A - Nocturia may result from decreased kidney-concentrating ability associated with aging. Increased production of antidiuretic hormone, decreased production of erythropoietin, and decreased secretion of aldosterone are age-related changes.

A nurse contacts the health care provider after reviewing a clients laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity

ANS: A - Normal BUN is 10 to 20 mg/dL. Normal creatinine is 0.6 to 1.2 mg/dL (males) or 0.5 to 1.1 mg/dL (females). Creatinine is more specific for kidney function than BUN, because BUN can be affected by several factors (dehydration, high-protein diet, and catabolism). This clients creatinine is normal, which suggests a non-renal cause for the elevated BUN. A common cause of increased BUN is dehydration, so the nurse should anticipate giving the client more fluids, not placing the client on fluid restrictions. Hemodialysis is not an appropriate treatment for dehydration. The lab results do not indicate an infection; therefore, a urine culture and sensitivity is not appropriate.

Which urinary assessment information for a client indicates the potential need for increased fluids? a. Increased blood urea nitrogen b. Increased creatinine c. Pale-colored urine d. Decreased sodium

ANS: A - Potential for increased fluids are needed for a client with increased blood urea nitrogen. Increased blood urea nitrogen can indicate dehydration. Increased creatinine indicates kidney impairment. Pale-colored urine signifies diluted urine, which indicates adequate fluid intake. Increased, not decreased, sodium indicates dehydration.

A nurse reviews laboratory results for a client who was admitted for a myocardial infarction and cardiogenic shock 2 days ago. Which laboratory test result should the nurse expect to find? a. Blood urea nitrogen (BUN) of 52 mg/dL b. Creatinine of 2.3 mg/dL c. BUN of 10 mg/dL d. BUN/creatinine ratio of 8:1

ANS: A - Shock leads to decreased renal perfusion. An elevated BUN accompanies this condition. The creatinine should be normal because no kidney damage occurred. A low BUN signifies overhydration, malnutrition, or liver damage. A low BUN/creatinine ratio indicates fluid volume excess or acute renal tubular acidosis.

After delegating to an unlicensed assistive personnel (UAP) the task of completing a bladder scan examination for a client, the nurse evaluates the UAPs performance. Which action by the UAP indicates the nurse must provide additional instructions when delegating this task? a. Selecting the female icon for all female clients and male icon for all male clients b. Telling the client, This test measures the amount of urine in your bladder. c. Applying ultrasound gel to the scanning head and removing it when finished d. Taking at least two readings using the aiming icon to place the scanning head

ANS: A - The UAP should use the female icon for women who have not had a hysterectomy. This allows the scanner to subtract the volume of the uterus from readings. If a woman has had a hysterectomy, the UAP should choose the male icon. The UAP should explain the procedure to the client, apply gel to the scanning head and clean it after use, and take at least two readings.

An older adult woman who reports a change in bladder function says, "I feel like a child who sometimes pees her pants." What is the nurse's best response? a. "Have you tried using the toilet at least every couple of hours?" b. "How does that make you feel?" c. "We can fix that." d. "That happens when we get older."

ANS: A - The nurse's best response to a client who states, "I feel like a child who sometimes pees her pants," is to ask the client if she uses the toilet at least every couple of hours. By emptying the bladder on a regular basis, urinary incontinence from overflow may be avoided, which may give the client some sense of control. The client has already stated how she feels. Asking her again does not address her concern, nor does it allow for nursing education. The nurse cannot assert that the problem can be fixed because this may be untrue. Suggesting that the problem occurs as we get older does not address the client's concern and does not provide for any client teaching.

A client has returned from a captopril renal scan. Which teaching does the nurse provide when the client returns to the unit? a. "Arise slowly and call for assistance when ambulating." b. "I must measure your intake and output." c. "We must save your urine because it is radioactive." d. "I must attach you to this cardiac monitor."

ANS: A - When a client returns to the unit from a captopril retinal scan, the nurse needs to teach the client to rise slowly and call for help when ambulating. Captopril can cause severe hypotension during and after the procedure. The client would be warned to avoid rapid position changes and about the risk for falling as a result of orthostatic (positional) hypotension. Intake and output measurement is not necessary after this procedure, unless it had been requested previously. The urine is not radioactive, because only a small amount of radioisotope is used in a renal scan. Standard Precautions need to be implemented and the nurse must wear gloves. Cardiac monitoring is not needed, although the nurse would monitor for hypotension secondary to captopril.

A nurse reviews a clients laboratory results. Which results from the clients urinalysis should the nurse identify as normal? (Select all that apply.) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e. Nitrate: small f. Leukocyte esterase: positive

ANS: A, B, D - The pH, specific gravity, and glucose are all within normal ranges. The other values are abnormal.

For which clients scheduled for a computed tomography (CT) scan with contrast does the nurse communicate safety concerns to the health care provider (HCP)? Select all that apply. a. Client with an allergy to shrimp b. Client with a history of asthma c. Client who requests morphine sulfate every 3 hours d. Client with a blood urea nitrogen of 62 mg/dL (22.1 mmol/L) and a creatinine of 2.0 mg/dL (177 umol/L) e. Client who took metformin (Glucophage) 4 hours ago

ANS: A, B, D, E - The nurse would communicate to the HCP CT scan contrast safety concerns about a client with an allergy to shrimp, a client with an asthma history, a client with an elevated BUN and creatinine, and a client who took Metformin 4 hours ago. All clients undergoing a CT scan with contrast would be asked about known hay fever or food or drug allergies, especially to seafood, eggs, milk, or chocolate. Contrast reactions have been reported to be as high as 15% in these clients. Clients with asthma have been shown to be at greater risk for contrast reactions than the general public. When reactions do occur, they are more likely to be severe. The risk for contrast-induced nephropathy is also increased in clients who have pre-existing renal insufficiency (e.g., serum creatinine levels greater than 1.5 mg/dL (133 umol/L) or estimated glomerular filtration rate less than 45 mL/min). Metformin must be discontinued at least 24 hours before and for at least 48 hours after any study using contrast media because the life-threatening complication of lactic acidosis, although rare, could occur. There are no contraindications to undergo CT scan with contrast while taking morphine sulfate. CT with contrast may help to identify the underlying cause of pain.

A nurse prepares a client for a percutaneous kidney biopsy. Which actions should the nurse take prior to this procedure? (Select all that apply.) a. Keep the client NPO for 4 to 6 hours. b. Obtain coagulation study results. c. Maintain strict bedrest in a supine position. d. Assess for blood in the clients urine. e. Administer antihypertensive medications.

ANS: A, B, E - Prior to a percutaneous kidney biopsy, the client should be NPO for 4 to 6 hours. Coagulation studies should be completed to prevent bleeding after the biopsy. Blood pressure medications should be administered to prevent hypertension before and after the procedure. There is no need to keep the client on bedrest or assess for blood in the clients urine prior to the procedure; these interventions should be implemented after a percutaneous kidney biopsy.

A nurse plans care for an older adult client. Which interventions should the nurse include in this clients plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. c. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the unlicensed assistive personnel (UAP). e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection.

ANS: A, B, E, F - The nurse should ensure that the client receives adequate fluid intake and has adequate lighting to ambulate safely to the bathroom at night, encourage the client to use the toilet every 2 hours, provide thorough perineal care after each voiding, and assess for urinary retention and urinary tract infections. The nurse should not delegate any teaching to the UAP, including bladder training instructions. The UAP may participate in bladder training activities, including encouraging and assisting the client to the bathroom at specific times.

A nurse assesses a client recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Decrease in urine output b. Tolerating oral fluids c. Prescription for metformin d. Blood clots present in the urine e. Burning sensation when urinating

ANS: A, D - The nurse should monitor urine output and contact the provider if urine output decreases or becomes absent. The nurse should also assess for blood in the clients urine. The urine may be pink-tinged, but gross bleeding or blood clots should not be present. If bleeding is present, the nurse should urgently contact the provider. Tolerating oral fluids is a positive outcome and does not need intervention. Metformin would be a concern if the client received dye; no dye is used in a cystoscopy procedure. The client may experience a burning sensation when urinating after this procedure; this would not require a call to the provider.

A nurse reviews a female clients laboratory results. Which results from the clients urinalysis should the nurse recognize as abnormal? a. pH 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color

ANS: B - Ketone bodies are by-products of incomplete metabolism of fatty acids. Normally no ketones are present in urine. Ketone bodies are produced when fat sources are used instead of glucose to provide cellular energy. A pH between 4.6 and 8, specific gravity between 1.005 and 1.030, and clear yellow urine are normal findings for a female clients urinalysis.

A nurse reviews the health history of a client with an oversecretion of renin. Which disorder should the nurse correlate with this assessment finding? a. Alzheimers disease b. Hypertension c. Diabetes mellitus d. Viral hepatitis

ANS: B - Renin is secreted when special cells in the distal convoluted tubule, called the macula densa, sense changes in blood volume and pressure. When the macula densa cells sense that blood volume, blood pressure, or blood sodium levels are low, renin is secreted. Renin then converts angiotensinogen into angiotensin I. This leads to a series of reactions that cause secretion of the hormone aldosterone. This hormone increases kidney reabsorption of sodium and water, increasing blood pressure, blood volume, and blood sodium levels. Inappropriate or excessive renin secretion is a major cause of persistent hypertension. Renin has no impact on Alzheimers disease, diabetes mellitus, or viral hepatitis.

The charge nurse is making client assignments for the day shift. Which client is best to assign to an LPN/LVN? a. Client who has just returned from having a kidney artery angioplasty b. Client with polycystic kidney disease who is having a kidney ultrasound c. Client who is going for a cystoscopy and cystourethroscopy d. Client with glomerulonephritis who is having a kidney biopsy

ANS: B - The best client to assign to an LPN/LVN is the client with polycystic kidney disease who is having a kidney ultrasound. Kidney ultrasounds are noninvasive procedures without complications, and the LPN/LVN can provide this care. A kidney artery angioplasty is an invasive procedure that requires post procedure monitoring for complications, especially hemorrhage. A registered nurse is needed for this client. Cystoscopy and cystourethroscopy are procedures that are associated with potentially serious complications such as bleeding and infection. These clients must be assigned to RN staff members. Kidney biopsy is associated with potentially serious complications such as bleeding, and this client would also be assigned to RN staff members.

Which laboratory test is the best indicator of kidney function? a. Blood urea nitrogen (BUN) b. Creatinine c. Aspartate aminotransferase (AST) d. Alkaline phosphatase

ANS: B - The laboratory test that is the best indicator of kidney function is creatinine excretion. Creatinine excretion, the end product of muscle metabolism, remains relatively steady and therefore is the best laboratory marker of renal function. BUN may be affected by protein, fluid intake, rapid cell destruction, cancer treatment, steroid therapy, and hepatic damage. AST and alkaline phosphatase are measures of hepatic function.

A nurse cares for a client with a urine specific gravity of 1.018. Which action should the nurse take? a. Evaluate the clients intake and output for the past 24 hours. b. Document the finding in the chart and continue to monitor. c. Obtain a specimen for a urine culture and sensitivity. d. Encourage the client to drink more fluids, especially water.

ANS: B - This specific gravity is within the normal range for urine. There is no need to evaluate the clients intake and output, obtain a urine specimen, or increase fluid intake.

The RN is caring for a client who has just had a kidney biopsy. Which action does the nurse perform first? a. Obtain blood urea nitrogen (BUN) and creatinine. b. Position the client supine. c. Administer pain medications. d. Check urine for hematuria.

ANS: B - When caring for a client after a kidney biopsy, the nurse first needs to position the client in a supine position. The client is positioned supine with a back roll for several hours after a kidney biopsy to decrease the risk for hemorrhage. BUN and creatinine would be obtained before the procedure is performed. Only local discomfort would be noted around the procedure site. Severe pain could indicate hematoma. Although pink urine may develop, the nurse would position the client to prevent bleeding first. The other actions are appropriate after this procedure, but do not need to be done immediately after the biopsy.

Which percussion technique does the nurse use to assess a client who reports flank pain? a. Place outstretched fingers over the flank area and percuss with the fingertips. b. Place one hand with the palm down flat over the flank area and use the other fisted hand to thump the hand on the flank. c. Place one hand with the palm up over the flank area and cup the other hand to percuss the hand on the flank. d. Quickly tap the flank area with cupped hands.

ANS: B - When performing percussion of a client's flank, the nurse needs to place one hand with the palm down flat over the costovertebral angle (CVA) of the flank area and, with the other fisted hand, thump the hand on the flank. Placing outstretched fingers, one hand palm up, and/or using cupped hands and quickly tapping the flank are incorrect techniques.

A nurse assesses clients on the medical-surgical unit. Which clients are at risk for kidney problems? (Select all that apply.) a. A 24-year-old pregnant woman prescribed prenatal vitamins b. A 32-year-old bodybuilder taking synthetic creatine supplements c. A 56-year-old who is taking metformin for diabetes mellitus d. A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain e. A 75-year-old with chronic obstructive pulmonary disease (COPD) who is prescribed an albuterol nebulizer

ANS: B, C, D - Many medications can affect kidney function. Clients who take synthetic creatine supplements, metformin, and high-dose or long-term NSAIDs are at risk for kidney dysfunction. Prenatal vitamins and albuterol nebulizers do not place these clients at risk.

A nurse cares for a client who is recovering from a closed percutaneous kidney biopsy. The client states, My pain has suddenly increased from a 3 to a 10 on a scale of 0 to 10. Which action should the nurse take first? a. Reposition the client on the operative side. b. Administer the prescribed opioid analgesic. c. Assess the pulse rate and blood pressure. d. Examine the color of the clients urine.

ANS: C An increase in the intensity of pain after a percutaneous kidney biopsy is a symptom of internal hemorrhage. A change in vital signs can indicate that hemorrhage is occurring. Before other actions, the nurse must assess the clients hemodynamic status.

When a client with diabetes returns to the medical unit after a computed tomography (CT) scan with contrast dye, all of these interventions are prescribed. Which intervention does the nurse implement first? a. Give lispro (Humalog) insulin, 12 units subcutaneously. b. Request a breakfast tray for the client. c. Infuse 0.45% normal saline at 125 mL/hr. d. Administer captopril (Capoten).

ANS: C - After a diabetic client returns to the unit after a CT scan, the first intervention implemented by the nurse is to infuse 0.45% normal saline at 125 mL/hour. Fluids are needed because the iodinated dye used in a CT scan with contrast has an osmotic effect, causing dehydration and potential kidney failure. Lispro is not administered until the breakfast tray arrives. A breakfast tray will be requested, but preventing complications of the procedure is done first. Because the client may be hypovolemic, the nurse needs to monitor blood pressure and administer IV fluids before deciding whether administration of captopril is appropriate.

Which instruction does the nurse give a client who needs a clean-catch urine specimen? a. "Save all urine for 24 hours." b. "Use the sponges to cleanse the urethra, and then initiate voiding directly into the cup." c. "Do not touch the inside of the container." d. "You will receive an isotope injection, then I will collect your urine."

ANS: C - Before obtaining a clean-catch urine specimen, the nurse instructs the client not to touch the inside of the container. A clean-catch specimen is used to obtain urine for culture and sensitivity of organisms present. Contamination by any part of the client's anatomy will render the specimen invalid and alter results. Saving urine for 24 hours is not necessary for a midstream clean-catch urine specimen. After cleaning, the client needs to initiate voiding into the commode, then stop and resume voiding into the container. Only 1 ounce (30 mL) is needed. The remainder of the urine may be discarded into the commode. A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra. A clean-catch specimen for culture does not require injection of an isotope before urine is collected.

When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which factor? a. Abdominal girth b. Presence of urinary infection c. History of hysterectomy d. Hematuria

ANS: C - Before performing bladder scanning to detect residual urine in a female client, the nurse must first determine if the client has had a hysterectomy. The scanner must be in the scan mode for female clients in order to ensure the scanner subtracts the volume of the uterus from the measurement. The nurse performs this procedure in response to distention or pressure in the bladder; girth is not a factor. This procedure detects urine retained in the bladder, not infection. The presence of retained urine in the bladder is assessed, regardless of hematuria.

A nurse teaches a client who is recovering from a urography. Which instruction should the nurse include in this clients discharge teaching? a. Avoid direct contact with your urine for 24 hours until the radioisotope clears. b. You may have some dribbling of urine for several weeks after this procedure. c. Be sure to drink at least 3 liters of fluids today to help eliminate the dye faster. d. Your skin may become slightly yellow from the dye used in this procedure.

ANS: C - Dyes used in urography are potentially nephrotoxic. A large fluid intake will help the client eliminate the dye rapidly. Dyes used in urography are not radioactive, the client should not experience any dribbling of urine, and the dye should not change the color of the clients skin.

A nurse assesses a client with renal insufficiency and a low red blood cell count. The client asks, Is my anemia related to the renal insufficiency? How should the nurse respond? a. Red blood cells produce erythropoietin, which increases blood flow to the kidneys. b. Your anemia and renal insufficiency are related to inadequate vitamin D and a loss of bone density. c. Erythropoietin is usually released from the kidneys and stimulates red blood cell production in the bone marrow. d. Kidney insufficiency inhibits active transportation of red blood cells throughout the blood.

ANS: C - Erythropoietin is produced in the kidney and is released in response to decreased oxygen tension in the renal blood supply. Erythropoietin stimulates red blood cell production in the bone marrow. Anemia and renal insufficiency are not manifestations of vitamin D deficiency. The kidneys do not play a role in the transportation of red blood cells or any other cells in the blood.

A nurse obtains a sterile urine specimen from a clients Foley catheter. After applying a clamp to the drainage tubing distal to the injection port, which action should the nurse take next? a. Clamp another section of the tube to create a fixed sample section for retrieval. b. Insert a syringe into the injection port and aspirate the quantity of urine required. c. Clean the injection port cap of the drainage tubing with povidone-iodine solution. d. Withdraw 10 mL of urine and discard it; then withdraw a fresh sample of urine.

ANS: C - It is important to clean the injection port cap of the catheter drainage tubing with an appropriate antiseptic, such as povidone-iodine solution or alcohol. This will help prevent surface contamination before injection of the syringe. The urine sample should be collected directly from the catheter; therefore, a second clamp to create a sample section would not be appropriate. Every sample from the catheter is usable; there is the need to discard the first sample.

A client is in the emergency department for an inability to void and for bladder distention. What is most important for the nurse to provide to the client? a. Increased oral fluids b. IV fluids c. Privacy d. Health history forms

ANS: C - It is most important for the nurse to provide privacy for this client. Besides privacy, the nurse also needs to help this client with assistance and voiding stimulants, such as warm water over the perineum, as needed.Increased oral fluids and IV fluids would exacerbate the client's problem. Obtaining a health history is not the priority for this client's care.

The nurse is teaching a client how to provide a clean-catch urine specimen. Which statement by the client indicates that teaching was effective? a. "I must clean with the wipes and then urinate directly into the cup." b. "I will have to drink 2 liters of fluid before providing the sample." c. "I'll start to urinate in the toilet, stop, and then urinate into the cup." d. "It is best to provide the sample while I am bathing."

ANS: C - Teaching is demonstrated to be effective when the client says, "I'll start to urinate in the toilet, stop, and then urinate into the cup." A midstream collection further removes secretions and bacteria because urine flushes the distal portion of the internal urethra. Although cleaning with wipes before providing a clean-catch urine sample is proper procedure, a step is missing. It is not necessary to drink 2 liters of fluid before providing a clean-catch urine sample. Providing a clean-catch urine sample does not involve bathing.

The nurse is reviewing the medical record for a client with polycystic kidney disease who is scheduled for computed tomographic angiography with contrast: Polycystic kidney disease Diabetes Hysterectomy Abdomen distended Negative edema Glyburide Metformin Synthroid BUN 26 mg/dL (9.2 mmol/L) Creatinine 1.0 mg/dL (77 umol/L) HbA1c 6.9% Glucose 132 mg/dL (7.3 mmol/L) Which intervention is essential for the nurse to perform? a. Obtain a thyroid-stimulating hormone (TSH) level. b. Report the blood urea nitrogen (BUN) and creatinine. c. Hold the metformin 24 hours before and on the day of the procedure. d. Notify the provider regarding blood glucose and glycosylated hemoglobin (HbA1c) values.

ANS: C - The essential intervention for the nurse to perform is to withhold metformin at least 24 hours before the time of a contrast media study and for at least 48 hours after the procedure because metformin may cause lactic acidosis. The focus of this scenario is the client with polycystic kidneys. A TSH level is not essential at this time. BUN and creatinine are normal. The glucose is only mildly elevated (if fasting), and the HbA1c is in an appropriate range.

The nurse visualizes blood clots in a client's urinary catheter after a cystoscopy. What nursing intervention does the nurse perform first? a. Administer heparin intravenously. b. Remove the urinary catheter. c. Notify the health care provider (HCP). d. Irrigate the catheter with sterile saline.

ANS: C - The nurse first notifies the HCP after visualizing a blood clot in a postoperative cystoscopy client's urinary catheter. Bleeding and/or blood clots are potential complications of cystoscopy and may obstruct the catheter and decrease urine output. In addition, the nurse must monitor urine output and notify the HCP of obvious blood clots or a decreased or absent urine output. Heparin would not be administered due to bleeding. The urinary catheter is allowing close monitoring of the urinary system and would not be removed at this time. The Foley catheter may be irrigated with sterile saline if prescribed by the HCP.

Which assessment finding alarms the nurse immediately after a client returns from the operating room for cystoscopy performed under conscious sedation? a. Pink-tinged urine b. Urinary frequency c. Temperature of 100.8°F (38.2°C) d. Lethargy

ANS: C - The nurse is immediately concerned when a postoperative cystoscopy client who had conscious sedation returns to the unit with a temperature of 100.8°F (38.2°C). Fever, chills, or an elevated white blood cell count after cystoscopy suggest infection after an invasive procedure. The provider must be notified immediately. Pink-tinged urine is expected after a cystoscopy. Frequency may be noted as a result of irritation of the bladder. Gross hematuria would require notification of the surgeon. If sedation or anesthesia was used, lethargy is an expected effect.

When caring for a client with uremia, the nurse assesses for which symptom? a. Tenderness at the costovertebral angle (CVA) b. Cyanosis of the skin c. Nausea and vomiting d. Insomnia

ANS: C - The signs and symptoms the nurse needs to assess for are nausea and vomiting. Other manifestations of uremia include anorexia, nausea, vomiting, muscle cramps, pruritus, fatigue, and lethargy. CVA tenderness is a sign of inflammation or infection in the renal pelvis. Cyanosis is related to poor tissue perfusion. Insomnia is nonspecific and may be caused by psychoemotional factors, medications, or other problems.

A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids. c. Assess the clients creatinine level. d. Increase the clients fluid intake.

ANS: D - Normal specific gravity for urine is 1.005 to 1.030. A high specific gravity can occur with dehydration, decreased kidney blood flow (often because of dehydration), and the presence of antidiuretic hormone. Increasing the clients fluid intake would be a beneficial intervention. Assessing the creatinine or obtaining a urine culture would not provide data necessary for the nurse to make a clinical decision.

A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take? a. Contact the provider and recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Obtain a suction device and implement seizure precautions. d. Encourage the client to drink more fluids.

ANS: D - Normal urine osmolality ranges from 300 to 900 mOsm/L. This clients urine is more concentrated, indicating dehydration. The nurse should encourage the client to drink more water. Dehydration can be associated with elevated serum sodium levels. Although a low-sodium diet may be appropriate for this client, this diet change will not have a significant impact on urine osmolality. A diuretic would increase urine output and decrease urine osmolality further. Low serum sodium levels, not elevated serum levels, place the client at risk for seizure activity. These options would further contribute to the clients dehydration or elevate the osmolality.

The nurse has these client assignments. Which client does the nurse encourage to consume 2 to 3 liters of fluid each day? a. Client with chronic kidney disease b. Client with heart failure c. Client with complete bowel obstruction d. Client with hyperparathyroidism

ANS: D - The nurse encourages the client with hyperparathyroidism to drink 2 to 3 liters of fluid each day. A major feature of hyperparathyroidism is hypercalcemia, which predisposes a client to kidney stones. This client must remain hydrated. A client with chronic kidney disease would not consume 2 to 3 liters of water because the kidneys are not functioning properly. Consuming that much fluid could lead to fluid retention. People with heart failure typically have fluid volume excess. A client with complete bowel obstruction may experience vomiting and would be NPO.

A client is scheduled for a cystoscopy later this morning. The consent form is not signed, and the client has not had any preoperative medication. The nurse notes that the health care provider (HCP) visited the client the day before. What action does the nurse take? a. Asks the client to sign the informed consent b. Cancels the procedure c. Asks the client's spouse to sign the form d. Notifies the department and the HCP

ANS: D - The nurse notifies both the HCP and the department to ensure effective communication across the continuum of care. This nursing action makes it less likely that essential information will be omitted. The client may be asked to sign the consent form in the department. The HCP gives the client a complete description of and reasons for the procedure and explains complications. The nurse reinforces this information. The procedure would not be cancelled without an attempt to correct the situation. The client has not received sedation, so nothing suggests that the client is not competent to consent and that the spouse needs to sign the form.

A nurse cares for a client who is having trouble voiding. The client states, I cannot urinate in public places. How should the nurse respond? a. I will turn on the faucet in the bathroom to help stimulate your urination. b. I can recommend a prescription for a diuretic to improve your urine output. c. Ill move you to a room with a private bathroom to increase your comfort. d. I will close the curtain to provide you with as much privacy as possible.

ANS: D - The nurse should provide privacy to clients who may be uncomfortable or have issues related to elimination or the urogenital area. Turning on the faucet and administering a diuretic will not address the clients concern. Although moving the client to a private room with a private bathroom would be nice, this is not realistic. The nurse needs to provide as much privacy as possible within the clients current room.

A client had a computed tomography (CT) scan with contrast dye 8 hours ago. Which nursing intervention is the priority for this client? a. Maintaining bedrest b. Medicating for pain c. Monitoring for hematuria d. Promoting fluid intake

ANS: D - The priority nursing intervention for this client is to promote fluid intake. The nurse must ensure that the client has adequate hydration to dilute and excrete the contrast media. The nurse urges the client to take oral fluid or, if needed, administers IV fluids to the client. Hydration reduces the risk for kidney damage. Bedrest is not indicated for the client who has undergone a CT scan with contrast dye. CT with contrast dye is not a painful procedure, so pain medication is not indicated. The client who has undergone CT with contrast dye is not at risk for hematuria.

One of the nurse's roles is talking to adult clients about urinary and sexual hygiene. Which words does the nurse use when referring to the client's reproductive body areas? a. Children's terms that are easily understood b. Slang words and terms that are heard "socially" c. Technical and medical terminology d. Words that the client uses

ANS: D - When talking to an adult client about urinary and sexual hygiene, the nurse uses words that the client uses. The nurse would use the terms with which the client is most familiar, so there is no chance for the client to misunderstand information. Using the client's language ensures the comfort level for the client. The use of children's terms is demeaning to adult clients. The use of slang terms is unprofessional. Technical terms would not be used because the client may not know what they mean.

A nurse cares for a client who has elevated levels of antidiuretic hormone (ADH). Which disorder should the nurse identify as a trigger for the release of this hormone? a. Pneumonia b. Dehydration c. Renal failure d. Edema

ANS: B - ADH increases tubular permeability to water, leading to absorption of more water into the capillaries. ADH is triggered by a rising extracellular fluid osmolarity, as occurs in dehydration. Pneumonia, renal failure, and edema would not trigger the release of ADH.

Which technique does the nurse use to obtain a sterile urine specimen from a client with a Foley catheter? a. Disconnect the Foley catheter from the drainage tube and collect urine directly from the Foley. b. Remove the existing catheter and obtain a sample during the process of inserting a new Foley. c. Use a sterile syringe to withdraw urine from the urine collection bag. d. Clamp the tubing, attach a syringe to the specimen, and withdraw at least 5 mL of urine.

ANS: D - The nurse will employ the technique of clamping the tubing, attaching a syringe to the specimen, and withdrawing at least 5 mL of urine when obtaining a sterile urine specimen from a client with a Foley catheter. Disconnecting the Foley catheter from the drainage tube and collecting urine directly from the Foley increases the risk for microbe exposure. A Foley catheter would not be removed to get a urine sample. Microbes may be in the urine collection bag from standing urine, so using a sterile syringe to withdraw urine from the urine collection bag is not the proper technique to obtain a sterile urine specimen.

A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take? a. Document findings and continue to monitor the client. b. Contact the provider and recommend a 24-hour urine test. c. Review the clients recent dietary selections. d. Perform a capillary artery glucose assessment.

ANS: D - Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the clients dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

When planning an assessment of the urethra, what does the nurse do first? a. Examine the meatus. b. Note any unusual discharge. c. Record the presence of abnormalities. d. Don gloves.

ANS: D - The nurse will first put on a pair of gloves. When assessing the urethra, the nurse needs to implement body fluid precautions before any other steps are taken. Examining the meatus, noting unusual discharge, and recording the presence of abnormalities are actions the nurse needs to perform after putting on gloves.