Passpoint Review

After undergoing a total cystectomy and urinary diversion, a client has a Kock pouch (continent internal reservoir) in place. Which statement by the client indicates a need for further teaching?

"I'll have to wear an external collection pouch for the rest of my life."

A nurse is collecting a health history on a client who's to undergo a renal angiography. Which statement by the client should be the priority for the nurse to address?

"I'm allergic to shellfish."

A client undergoes extracorporeal shock wave lithotripsy. Before discharge, the nurse should provide which instruction?

"Increase your fluid intake to 2 to 3 L per day."

A graduate nurse is asking for information about chronic renal failure. Which statement by the nurse would be most accurate when providing teaching?

"It is characterized by azotemia, fluid volume excess, and hyperkalemia."

A client was treated for a streptococcal throat infection 2 weeks ago. The client now has been diagnosed with acute poststreptococcal glomerulonephritis. The client asks the nurse how he could have prevented this condition. What should the nurse tell the client?

"See your health care provider (HCP) for an early diagnosis and treatment of a sore throat."

In the emergency department, a client reveals to the nurse a lethal plan for dying by suicide and agrees to a voluntary admission to the psychiatric unit. Which information would the nurse discuss with the client to answer the question "How long do I have to stay here?" Select all that apply.

-"You may leave the hospital at any time unless you're suicidal or homicidal or unable to meet your basic needs." -"Let's talk after the health care team has assessed you." -"Because you have stated that you want to hurt yourself, you must be safe before being discharged."

The nurse is developing a care management plan with a client who has been diagnosed with gastroesophageal reflux disease. What should the nurse instruct the client to do? Select all that apply.

-Avoid a diet high in fatty foods. -Avoid beverages that contain caffeine. -Avoid all alcoholic beverages.

A client has undergone a cystectomy and an ileal conduit diversion. What should the nurse include in the discharge instructions? Select all that apply.

-Avoid odor-producing foods, such as onions, fish, eggs, and cheese. -Drink at least 3,000 mL of fluid each day.

A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of the body. Admission vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply.

-Begin an intravenous (I.V.) infusion of lactated Ringer's solution. -Administer 6 mg of IV morphine. -Administer tetanus prophylaxis, as ordered.

Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.

-Infuse a unit of PRBCs in less than 4 hours. -Stop the transfusion if a reaction occurs, but keep the line open. -Inspect the blood bag for leaks, abnormal color, and clots.

The nurse is caring for a client with acute renal failure and edema. Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

-Make sure the urinal is within the client's reach. -Remind the client that all urine is to be saved for intake and output measurement. -Weigh the client every morning using the standing scale. -`Measure and record vital signs.

A nurse is caring for a client who is disoriented to time, place, and person and is attempting to get out of bed and pull out an intravenous line. The nurse receives orders from a health care provider to apply a vest restraint and bilateral soft wrist restraints. In carrying out this order, which nursing actions would be appropriate? Select all that apply.

-Perform a face-to-face behavior evaluation every hour. -Tie the restraints in quick-release knots. -Document the client's condition. -Document alternative methods used before the restraints were applied. -Document the client's response to the intervention.

A client has a tumor of the posterior pituitary gland. The nurse planning the client's care would include which interventions? Select all that apply.

-Weigh the client daily. -Measure urine specific gravity. -Monitor intake and output.

The nurse is caring for a client that has a low potassium level. What medication(s) would the nurse be concerned about administering to this client? Select all that apply.

-digoxin -furosemide

An older adult is admitted with new-onset confusion, headache, poor skin turgor, bounding pulse, and urinary incontinence and has been drinking copious amounts of water. Upon reviewing the lab results, the nurse discovers a sodium level of 122 mEq/L (122 mmol/L). A report to the health care provider (HCP) should include what recommendations? Select all that apply.

-fluid restriction vital signs every 2 -hours -bed alarm -Foley catheter

A client is seen in the clinic for newly diagnosed hypothyroidism. Which topics should the nurse include in a client teaching plan? Select all that apply.

-high-fiber, low-calorie diet -use of stool softeners -thyroid hormone replacements

A client is placed on hypocalcemia precautions after removal of the parathyroid gland for cancer. The nurse should observe the client for which symptoms? Select all that apply.

-numbness -tingling -muscle twitching and spasms

A client is scheduled for a creatinine clearance test. The nurse should explain that this test is done to assess the kidneys' ability to remove a substance from the plasma in

1 minute.

Following a transurethral resection of the prostate (TURP), a client is receiving a normal saline 0.9% irrigation solution at 200 mL/hour. The client has a peripheral IV running at 125 mL/hour and has consumed 300 mL of water. After 8 hours, the nurse empties 3100 mL of fluid from the Foley bag. What is the 8-hour urinary output for this client? Record the answer as a whole number.

1500

A nurse is preparing to administer a unit of blood to a client with anemia. After its removal from the refrigerator, the blood should be administered within:

4 hours.

The nurse is reading the nurse's note from the previous shift to evaluate the client with a risk for impaired skin integrity due to fluid volume excess. Which aspects would demonstrate this improvement?

Ambulation to the bathroom without noted dyspnea.

A client returns from extracorporeal shock wave lithotripsy with ecchymosis over the left flank area. Vital signs are within normal limits, and the client appears to be in no acute distress. Which nursing action is appropriate?

Apply a cold compress to the site.

The client asks the nurse, "Is it really possible to lead a normal life with an ileostomy?" Which action by the nurse would be the most effective to address this question?

Arrange for a person with an ostomy to visit the client preoperatively.

A client who had transurethral resection of the prostate (TURP) 2 days earlier has lower abdominal pain. What should the nurse do first?

Assess the patency of the urethral catheter.

A client undergoes cystoscopy with bladder biopsy. After the procedure, which assessment is most appropriate for the nurse to make?

Assess urine for excessive bleeding.

A client undergoes a nephrectomy. In the immediate postoperative period, which nursing intervention has the highest priority?

Assess urine output hourly.

A client with chronic renal failure receives hemodialysis treatments through a mature arteriovenous (AV) fistula. What intervention will the nurse include in the care plan?

Auscultate the AV fistula for a bruit.

A client with end-stage renal failure has an internal arteriovenous fistula in the left arm for vascular access during hemodialysis. What should the nurse instruct the client to do? Select all that apply.

Avoid sleeping on the left arm. Wear wrist watch on the right arm. Assess fingers on the left arm for warmth.

A client is admitted with a diagnosis of chronic hydronephrosis. Which assessment finding requires immediate action or will assist the nurse in planning care?

Client's blood urea nitrogen (BUN) is 32 mg/dL.

The nurse instructs the unlicensed assistive personnel on how to collect a 24-hour urine specimen. Which of the following instructions is correct for a collection that is scheduled to start at 7 a.m. (0700) Monday and end at 7 a.m. (0700) Tuesday?

Collect and save the urine voided at 7 a.m. (0700) on Tuesday.

The nurse is caring for a client with a gastrostomy tube. Fifteen minutes after a bolus feeding the client experiences bloating, cramping, diarrhea, dizziness, diaphoresis, and weakness. What action should the nurse take?

Contact the healthcare provider to alter the enteral feeding prescription.

The nurse caring for a client with an arteriovenous (AV) fistula notes that the fingers distal to the fistula are cold to the touch and the capillary refill time is greater than 3 seconds. What is the priority action by the nurse?

Contact the healthcare provider.

The nurse is planning care for a client with stress incontinence. What goal is realistic for the nurse to establish with the client?

Decrease the number of incontinence episodes.

A client with benign prostatic hypertrophy has an elevated prostate-specific antigen (PSA) level. What should the nurse do next?

Determine if the prostatic palpation was done before or after the blood sample was drawn.

Which information would the nurse include in the teaching plan for a 32-year-old female client requesting information about using a diaphragm for family planning?

Diaphragms should not be used if the client develops acute cervicitis.

After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. What should the nurse do to prevent a urinary tract infection?

Empty the urinary appliance before it is one-third full.

The nurse is assessing the urine of a client who has had an ileal conduit and notes that there is a moderate amount of mucus in the urine. What should the nurse do next?

Encourage a high fluid intake.

The nurse and parents plan for the discharge of a child with leukemia who is receiving dactinomycin and vincristine. Which intervention should the nurse include in the teaching plan?

Encourage increased fluid intake.

The nurse warms the dialysis solution before use in peritoneal dialysis. What is the expected outcome of warming the solution?

Encourage the removal of serum urea.

A nurse is reviewing a client's fluid intake and output record. Fluid intake and urine output should relate in which way?

Fluid intake should be about equal to the urine output.

After surgery to remove a ruptured fallopian tube, a multigravid client receives discharge instructions about potential complications to report to her physician. Which of the following, if stated by the client as a complication, indicates a need for additional teaching?

Headache.

A client is scheduled for a creatinine clearance test. What should the nurse do to prepare the client?

Instruct the client about the need to collect urine for 24 hours.

Which action would be most appropriate for preventing urinary tract infections in an elderly female client?

Instruct the client to avoid tight-fitting underwear.

A client is having peritoneal dialysis. During the exchange, the nurse observes that the solution draining from the client's abdomen is consistently blood tinged. The client has a permanent peritoneal catheter in place. What clinical judgment should the nurse make about the blood-tinged drainage?

It indicates abdominal blood vessel damage.

Two weeks after being diagnosed with a streptococcal infection, a client develops fatigue, a low-grade fever, and shortness of breath. The nurse auscultates bilateral crackles and observes jugular vein distention. Urinalysis reveals red and white blood cells and protein. After the physician diagnoses poststreptococcal glomerulonephritis, the client is admitted to the medical-surgical unit. Which immediate action should the nurse take?

Monitor patient blood pressure.

A nurse is caring for an 8-year-old female with multiple, chronic urinary tract infections. While the nurse helps the child's parent provide morning care, the child states, "My uncle doesn't clean me that way." The parent becomes visibly upset and gives the girl a stern warning not to discuss the matter. What is the priority action for the nurse?

Notify the nursing supervisor and the authorities of the possibility of abuse.

A school-age child with glomerulonephritis reports a headache and blurred vision. What immediate action should the nurse take?

Obtain the child's blood pressure.

A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. What information should the nurse give to the client?

Report any difficulty urinating.

During dialysis, the client has disequilibrium syndrome. What should the nurse do first?

Slow the rate of dialysis.

The nurse suspects an air embolism in a client receiving hemodialysis. Place the actions by the nurse in the correct order. All options must be used.

Stop the hemodialysis. Place client on left side in Trendelenburg position. Notify the rapid response team. Administer oxygen. Assess vital signs.

A nurse is about to admit a client to the medical surgical unit directly from the healthcare provider's office. Upon assessment, the nurse notes that the client has significant periorbital edema. Laboratory values indicate the presence of proteinuria and hypoproteinemia. Which action is the nurse's priority?

Strict intake and output assessment and documentation

A female client has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this client?

This condition puts the client at a higher risk for cervical cancer; therefore, she should have a Papanicolaou (Pap) smear annually.

The client is having peritoneal dialysis. During the exchange, the nurse observes that the flow of dialysate stops before all the solution has drained out. What should the nurse do next?

Turn the client from side to side.

Which teaching approach for the client with chronic renal failure who has difficulty concentrating due to high uremia levels would be most appropriate?

Validate the client's understanding of the material frequently.

The nurse is obtaining a health history from a client with a sexually transmitted disease. Which description from the client indicates the likelihood of syphilis? "In my genital area I have:

a moist ulcer."

The nurse should teach the client with erectile dysfunction (ED) to alter his lifestyle by doing which?

avoiding alcohol

A client has nephrotic syndrome. To aid in the resolution of the client's edema, the health care provider prescribes 25% albumin. In addition to an absence of edema, the nurse should evaluate the client for which expected outcome?

blood pressure elevation

A client returns to the intensive care unit after coronary artery bypass graft surgery, which was complicated by a prolonged cardiopulmonary bypass and hypotension. After 3 hours in the unit, the client's condition stabilizes. Which assessment finding indicates a potential complication related to this occurrence?

blood urea nitrogen level (BUN) of 40 mg/dL

Following the acute stage of diverticulosis, which foods should the nurse encourage a client to incorporate into the diet? Select all that apply.

bran cereal broccoli navy beans

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

cardiac arrhythmia.

The nurse is caring for a client during the first 72 hours after thyroidectomy. The nurse should assess for which signs of complications of this surgery?

carpal spasms and facial numbness

Which hospitalized client is at highest risk for catheter associated urinary tract infection (CAUTI)?

client with diabetes mellitus

A female client is experiencing bladder control problems. Which outcome indicates the success of nursing interventions to promote urinary continence for this client?

continence for 24 hours a day

The nurse is teaching an older adult with a urinary tract infection about the importance of increasing fluids in the diet. What puts this client at a risk for not obtaining sufficient fluids?

decreased ability to detect thirst

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance?

decreased serum sodium level

The nurse is caring for a client with a serum sodium level of 128 mEq/L. Which order for intravenous fluids should the nurse should question?

dextrose 5% in water (D5W)

To treat a urinary tract infection, a client is ordered sulfamethoxazole-trimethoprim. The nurse should teach the client that sulfamethoxazole-trimethoprim is most likely to cause which adverse effect?

diarrhea

A client has prostatic hypertrophy. What should the nurse assess when conducting a focused assessment of the client's ability to urinate?

difficulty starting the flow of urine

Which finding in the client's history would be the least likely to have predisposed the client to renal calculi?

drinking less than the recommended amount of milk

A client receiving dialysis directs profanities at the nurse and then abruptly hangs his head and pleads, "Please forgive me. Something just came over me. Why do I say those things?" The nurse interprets this as which finding?

emotional lability

Which should be the nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease?

enhance myocardial oxygenation

A client with type 2 diabetes mellitus who is taking metformin is scheduled for a computed tomography (CT) with contrast of the abdomen tomorrow. Which priority nursing assessment is done before the procedure?

ensuring that the metformin has been withheld for 48 hours prior to the scan

When providing discharge teaching for a client with uric acid calculi, the nurse would include an instruction to avoid which type of diet?

high purine

Which factor would put the client at increased risk for pyelonephritis?

history of diabetes mellitus

The nurse should monitor the client with Cushing's disease for which finding?

hypokalemia

A nurse is caring for a client with acute pyelonephritis. Which nursing intervention is the most important?

increasing fluid intake to 3 L/day

The nurse is caring for a client with acute renal failure. Rank in chronological order the phases of acute renal failure. All options must be used.

initial insult oliguric phase diuretic phase recovery phase

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

kidney

For a client in the oliguric phase of acute renal failure (ARF), which nursing intervention is the most important?

limiting fluid intake

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

milk

After trying for a year to conceive, a couple consults an infertility specialist. When obtaining a history from the husband, the nurse asks about childhood infectious diseases. Which childhood infectious disease most significantly affects male fertility?

mumps

An elderly client has been admitted to the medical-surgical unit from the postanesthesia care unit. While the nurse is off the floor, the client falls out of bed and fractures the right leg and right wrist. The nurse finding the client states, "The side rails were down and the bed was in the high position." The client's family files legal charges against the nurse and the hospital. Which charge most accurately reflects the nurse's actions?

negligence

A nurse is providing postprocedure care for a client who underwent percutaneous lithotripsy. In this procedure, an ultrasonic probe inserted through a nephrostomy tube into the renal pelvis generates ultra-high-frequency sound waves to shatter renal calculi. The nurse should instruct the client to:

notify the physician about cloudy or foul-smelling urine.

A client is to receive belladonna and opium suppositories, as needed, postoperatively after transurethral resection of the prostate (TURP). The nurse should give the client these drugs when he demonstrates signs of which symptom?

pain from bladder spasms

A client is admitted for treatment of glomerulonephritis. On initial assessment, the nurse detects one of the classic signs of acute glomerulonephritis of sudden onset. Such signs include:

periorbital edema.

A client is started on sulfamethoxazole-trimethoprim for reports of severe burning on urination and frequent, urgent voiding of small amounts of urine. As the nurse explains the medication, the client requests something to relieve the painful urination. Which treatment order would the nurse anticipate for the client's discomfort?

phenazopyridine

The nurse should monitor the client with acute pancreatitis for which complication?

pneumonia

The client is in the oliguric phase of acute renal failure. For which risk should the nurse assess the client?

pulmonary edema

A client with chronic renal failure has a serum potassium level of 6.8 mEq/L. What should the nurse assess first?

pulse

The client with an ileal conduit will be using a reusable appliance at home. The nurse should teach the client to clean the appliance routinely with which product?

soap

A nurse is providing in-service education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step?

supporting the client's emotional status

A client believes she is experiencing premenstrual syndrome (PMS). The nurse should next ask the client about what symptom?

tension and fatigue before menses and through the second day of the menstrual cycle

Which client has a need for prophylactic antibiotic therapy prior to dental manipulations?

the client who had an aortic valve replacement 5 years ago

Which client will the nurse prioritize to assess first?

the client with ESRD (end-stage renal disease) just admitted the night before

A nurse has a four-patient assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology?

the client with diabetes insipidus

The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. The nurse should report which finding to the health care provider (HCP)?

urine output: 20 mL/h

An adolescent client is hospitalized with acute glomerulonephritis. The nurse reviews the client's urine chemistry laboratory reports (see figure). Which finding does the nurse draw to the attention of the health care provider (HCP)?

urine specific gravity

Which factor should be checked when evaluating the effectiveness of an alpha-adrenergic blocker given to a client with benign prostatic hyperplasia (BPH)?

voiding pattern

After completion of peritoneal dialysis, for which symptom should the nurse assess the client?

weight loss

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding during this procedure signals a significant problem?

white blood cell (WBC) count of 20,000/mm3 (0.02 L)