NUS111: URINARY ELIMINATION
Which client is at highest risk for developing a hospital-acquired infection? A client with a laceration to the left hand A client who's taking prednisone (Deltasone) A client with an indwelling urinary catheter A client with Crohn's disease
A client with an indwelling urinary catheter Explanation: The invasive nature of an indwelling urinary catheter increases the client's risk of a hospital-acquired infection. The nurse must perform careful, frequent catheter care to minimize the client's risk. Although the client with a laceration, the client who's taking prednisone, and the client with Crohn's disease have a risk of infection, the one with an indwelling catheter is at the greatest risk.
The nurse is caring for several older clients. For which client would the nurse be especially alert for signs and symptoms of pyelonephritis? A client with acute renal failure A client with a urinary tumor A female client with preexisting chronic glomerulonephritis A client with urinary obstruction
A client with urinary obstruction Explanation: The client with urinary obstruction is at the highest risk of developing pyelonephritis because a urinary obstruction is the most common cause of pyelonephritis in older adults. Acute glomerulonephritis usually occurs in older adults with preexisting chronic glomerulonephritis. Older clients with acute renal failure or urinary tumor are not at high risk for developing pyelonephritis.
After undergoing renal arteriogram, in which the left groin was accessed, a client complains of left calf pain. Which intervention should the nurse perform first? Assess peripheral pulses in the left leg. Place cool compresses on the calf. Exercise the leg and foot. Assess for anaphylaxis.
Assess peripheral pulses in the left leg. Explanation: 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.
The nurse has been asked to provide health information to a female patient diagnosed with cystitis. Select all the teaching points that apply. Cleanse around the perineum and urethral meatus after each bowel movement. Drink caffeinated beverages twice a day to increase urination. Drink liberal amounts of fluid. Void no more frequently than every 6 hours to allow urine to dilute the bacteria in the bladder.
Cleanse around the perineum and urethral meatus after each bowel movement. Drink liberal amounts of fluid. Void no more frequently than every 6 hours to allow urine to dilute the bacteria in the bladder.
The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find? Hyperalbuminemia Peripheral neuropathy Cola-colored urine Hypotension
Cola-colored urine Explanation: Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria.
The nurse is caring for a client who had transurethral resection of the prostate (TURP) 1 day ago. Which assessment finding(s) does the nurse expect? Select all that apply. Large amounts of amber-colored urine in the drainage bag Rounded swelling above the pubis Reports of the urge to void from the client Drainage tube secured to the inner thigh Increasing pulse rate and diaphoresis
Large amounts of amber-colored urine in the drainage bag Reports of the urge to void from the client Drainage tube secured to the inner thigh
The nurse is caring for a patient who had a transurethral resection of the prostate (TURP). The health care provider has ordered continuous bladder irrigation, and the patient is now around 20 hours postoperative. During the nurse's shift assessment, what color urine would the nurse expect to find in the drainage bag? Red-pink Tea-colored Amber Light pink
Light pink Explanation: The urine drainage following a TURP usually begins as a reddish pink and then clears to a light pink 24 hours after surgery.
The nurse performs a physical examination on a client diagnosed with acute pyelonephritis to assist in determining which of the following? Abnormalities in urine Location of discomfort Elevated calcium levels Structural defects in the kidneys
Location of discomfort Explanation: The physical examination of a client with pyelonephritis helps the nurse determine the location of discomfort and signs of fluid retention, such as peripheral edema or shortness of breath. Observing and documenting the characteristics of the client's urine helps the nurse detect abnormalities in the urine. Laboratory blood tests reveal elevated calcium levels, whereas radiography and ultrasonography depict structural defects in the kidneys.
A female client is undergoing a bladder training program as treatment for urinary incontinence. Which technique would be the most appropriate for the nurse to suggest? Performing Kegel exercises Reducing fluid intake Attempting to hold the urine for five minutes until the sensation is felt Taking warm sitz baths
Performing Kegel exercises Explanation: Instructing the client on Kegel exercises will help the client achieve continence. These exercises improve muscle tone and voluntary control. Reducing fluids will not change continence or aid in muscle strength. Holding the urine until the sensation is felt will not aid in muscle strength. Warm sitz baths may be suggested to a client in the event of urethra inflammation.
Which laboratory value supports a diagnosis of pyelonephritis? Myoglobinuria Ketonuria Pyuria Low white blood cell (WBC) count
Pyuria Explanation: Pyelonephritis is diagnosed by the presence of pyuria, leukocytosis, hematuria, and bacteriuria. The client exhibits fever, chills, and flank pain. Myoglobinuria is seen with any disease process that destroys muscle. Ketonuria indicates a diabetic state. Because the client with pyelonephritis typically has signs of infection, the WBC count is more likely to be high rather than low.
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant? Previous episode of acute pyelonephritis History of hyperparathyroidism Recent history of streptococcal infection History of osteoporosis
Recent history of streptococcal infection Explanation: Glomerulonephritis can occur as a result of infections from group A beta-hemolytic streptococcal infections, bacterial endocarditis, or viral infections such as hepatitis B or C or human immunodeficiency virus (HIV). A history of hyperparathyroidism or osteoporosis would place the client at risk for developing renal calculi. A history of pyelonephritis would increase the client's risk for chronic pyelonephritis.
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder? Acute renal failure Acute glomerulonephritis Chronic renal failure Nephrotic syndrome
Acute glomerulonephritis Explanation: Acute glomerulonephritis is also associated with varicella zoster virus, hepatitis B, and Epstein-Barr virus. Acute renal failure is associated with hypoperfusion to the kidney, parenchymal damage to the glomeruli or tubules, and obstruction at a point distal to the kidney. Chronic renal failure may be caused by systemic disease, hereditary lesions, medications, toxic agents, infections, and medications. Nephrotic syndrome is caused by disorders such as chronic glomerulonephritis, systemic lupus erythematosus, multiple myeloma, and renal vein thrombosis. Reference:
A pediatric nurse is providing care for a 7-year-old boy who has been diagnosed with glomerulonephritis. In addition to monitoring this child's blood work closely, what other assessment should prioritized in order to gauge the progression of his disease? Daily weights Assessment of skin turgor Chest auscultation Apical heart rate
Daily weights Explanation: The most accurate indicator of fluid loss or gain in an acutely ill patient with renal disease is weight, as accurate intake and output and assessment of insensible losses may be difficult. Daily weights would thus be prioritized over respiratory auscultation and apical heart rate, although each should be conducted because of their relevance to the complications of glomerulonephritis. Assessment of skin turgor is not an accurate indicator of fluid balance.
A patient is recovering in the PACU following a transurethral resection of the prostate (TURP). The patient is receiving continuous bladder irrigation (CBI), and the nurse has observed several clots in the collection bag and tubing. In the last few minutes, output has ceased despite the continued infusion of normal saline through the patient's triple-lumen urinary catheter. How should the nurse respond to this assessment finding? Slow the rate of CBI to half of the previous rate. Reposition the patient to a semi-Fowler's position. Manually irrigate the patient's catheter with normal saline. Remove the triple-lumen catheter and replace it with a double-lumen catheter.
Manually irrigate the patient's catheter with normal saline. Explanation: The nurse monitors the CBI drainage tubing and irrigates the system as prescribed to relieve any obstruction that may cause discomfort. Usually, if clots impede urinary drainage, the catheter is irrigated with 50 to 60 mL of irrigating fluid at a time. It would be inappropriate to remove the catheter, and it would be ineffective to slow the infusion or reposition the patient.
The nurse is caring for a client with a cystoscopy tube draining urine from the bladder. When reviewing the client's history prior to administering care, which is of most concern? Diagnostic studies reporting bladder stones Crusted drainage around the cystoscopy tube A white blood count of 12,000 cells/mm3 New diagnosis of urosepsis
New diagnosis of urosepsis Explanation: All of the options are typical risk factors for a client with a cystoscopy tube. The most concerning risk factor is of urosepsis, which is a serious systemic infection from microorganisms in the urinary tract invading the bloodstream.
The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply. For those patients who are incontinent, insert indwelling catheters. Perform hand hygiene prior to patient care. Assist the patients with frequent toileting. Provide careful perineal care. Encourage patients to wear briefs.
Perform hand hygiene prior to patient care. Assist the patients with frequent toileting. Provide careful perineal care.
When caring for the patient with acute glomerulonephritis, which of the following assessment findings should the nurse anticipate? Tea-colored urine Left upper quadrant pain Pyuria Low blood pressure
Tea-colored urine Explanation: Tea-colored urine is a typical symptom of glomerulonephritis. Flank pain on the affected side, not left upper quadrant pain, would be present. Pyuria is a symptom of pyelonephritis, not glomerulonephritis. Blood pressure typically elevates in glomerulonephritis.
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? The urine in the drainage bag appears red to pink. The client reports bladder spasms and the urge to void. The normal saline irrigant is infusing at a rate of 50 drops/minute. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned.
The client reports bladder spasms and the urge to void. Explanation: 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/minute 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.